Every finding on record at South Jersey Extended Care

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to store utensils in a clean, dry location; not exposed to splash, dust, or other contaminations, and failed to keep utensils covered or inverted to maintain sanitation in a safe, consistent manner. This deficient practice was evidenced by the following:On 11/19/25 at 10:30 AM, the surveyor, in the presence of the Food Service Director (FSD), observed in the facility kitchen, a white bin labeled Flour, with a clear top. Inside of the container, the surveyor noted a white powder and a clear plastic scoop utensil resting within the powder. When asked whether the scoop utensil was normally kept within the product, the FSD responded no, they should not be left in the flour, they should be cleaned and placed in the drying area after use for sanitary reasons. On 11/20/25 at 1:53 PM, a pink wash basin was observed sitting on top of the ice machine on the C/D unit. One clear plastic and one metal ice scoop utensil were each noted within the wash basin. The ice machine appeared to be locked at the time.On 11/21/25 at 12:34 PM, the surveyor observed a pink wash basin sitting on top of the ice machine on the C/D unit. The clear plastic and metal ice scoop utensils were observed resting within the wash basin.On 11/24/25 at 10:19 AM, the surveyor noted the metal and plastic ice scoop utensils located within the pink wash basin on the C/D unit ice machine. At that time, the surveyor interviewed the Licensed Practical Nurse (LPN) #1 regarding the use and storage of the ice scoop utensils. LPN #1 confirmed that residents were given ice from the machine using the scoops each shift and as requested for their personal cups and pitchers of water. When asked if the ice scoop utensils were usually kept in the wash basin, LPN #1 replied yes and explained they were kept in the pink basin because the metal scoop did not fit in the hanger and neither did the plastic scoop since the ice machine was changed out. When asked who was responsible for cleaning the machine and the ice scoop utensils, LPN #1 replied that the Housekeeping Department maintained them. The surveyor then asked LPN #1 if any potential problems could arise with storing the ice scoops in an open wash basin; LPN #1 replied that moisture could sit with no place to go, which could harbor bacteria.On 11/24/25 at 10:52 AM, the surveyor observed the ice machine on the A/B unit in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM) #2, a plastic ice scoop utensil resting within a protective hanger laying horizontally on top of the ice machine. The surveyor interviewed LPN/UM #2 who confirmed that residents were given ice from the machine using the scoop utensil each shift and as needed, like on the C/D unit. When asked if the holder was usually laying horizontal with the ice scoop utensil inside, LPN/UM #2 stated she was unsure of when it was taken from the wall, but it used to be hanging and was unsure why it was not replaced. When asked if any potential problem could arise from storing the ice scoop utensil horizontally within the holder on top of the ice machine instead of inverted on the wall as designed, LPN/UM #2 replied that without proper drainage, bacteria could grow and potentially make people sick.On 11/24/25 at 11:37 AM, the surveyor toured with the Director of Environmental Services and Maintenance (DESM) to observe the storage of the ice scoop utensils and address concerns regarding their sanitary storage. The DESM stated that while he had a cleaning log and maintenance log for the ice machine, no specific log was kept for the ice scoop utensil cleaning; he stated that he was unsure when they were last cleaned and that the Certified Nursing Assistants (CNA) could clean them but could not offer any evidence that they were ever cleaned. When asked about the sanitary storage of the ice scoop utensils and what potential problems could arise from their storage in a wash basin or a cover placed horizontally on top of an ice machine the DESM responded, there could be contamination, cross-contamination, or even a legionnaires risk.On 11/25/25 at 10:20 AM, the surveyor's concerns were presented to the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA). In the presence of the survey team, both acknowledged that scoop utensils should not be stored within the product, a wash basin, or horizontally within its cover to prevent the spread of infection. A review of a facility's Food Storage/Labeling policy, undated, included: Scoops must be provided for bulk foods (such as sugar, flour.). Scoops should be kept covered in a protected area near the containers rather than in the containers. Scoops should be washed and sanitized on a regular basis.A review of a facility's Care, Cleaning and Storage of Equipment policy, undated, included: Equipment found to be in disrepair (e.g. paper towel dispensers, hand soap dispensers, etc.) should be reported to the supervisor on the day it is noted.NJAC 8:39-17.2 (g); 19.7 (d)

Based on interview, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete reference checks on employees before their start date. The deficient practice was identified for 6 of 107 employees (Employee #1, Employee #2, Employee #3, Employee #4, Employee #5, and Employee #6), reviewed and was evidenced by the following:On 11/19/25 at 10:24 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) the personnel files of all the new employees who were hired since the last standard survey (6/19/2024), whether currently employed or terminated, for review by the survey team. A review of the employee personnel files revealed the following: For Employee #1, a Housekeeper with a start date of 8/20/24, there was no evidence of a reference check prior to the start of employment. For Employee #2, a Registered Nurse (RN) with a start date of 11/6/24, there was no evidence of a reference check prior to the start of employment. For Employee #3, a Certified Nursing Assistant, with a start date of 9/12/24, there was no evidence of a reference check prior to start of employment. For Employee #4, a Licensed Practical Nurse (LPN) with a start date of 4/9/25, there was no evidence of a reference check prior to the start of employment. For Employee #5, a LPN with a start date of 9/24/24, there was no evidence of a reference check prior to the start of employment. For Employee #6, a RN with a start date of 8/16/24, there was no evidence of a reference check prior to the start of employment. On 11/25/25 at 10:31 AM, the surveyor interviewed the Director of Human Resources (DHR), in the presence of the survey team about the facility's screening process for new hires. The DHR stated the facility completed reference checks prior to the first day of employment to ensure that the potential employee had nothing bad against them, such as abuse against a resident. She further stated that if the employee did not have reference checks completed prior to the hire date, then the employee would not be hired. A review of the facility's Abuse, Neglect and Exploitation policy, revised 1/3/25, included, .potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credential's checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. the facility will maintain documentation of proof that the screening occurred . NJAC 8:39-4.1(a)(5); 9.3(b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe, comfortable, and home-like environment for a.) residents who required the use of a wheelchair (Resident #5, #15, #29, #37, #50, #52, #and #56) and b.) a resident who required the use of an over the toilet commode (Resident #5). This deficient practice was identified on 2 of 2 units, A/B Unit and C/D Unit, and was evidenced the following:On 11/19/2025 at 11:33 AM, the surveyor observed Resident #74 in the hallway, seated in a wheelchair on a seat cushion. The seat cushion had a large amount of residue buildup on the sides and a rip along the right lateral side of the cushion. The wheelchair contained a large amount of thick residue on the seat and the frame.On 11/21/2025, at 8:29 AM, during a follow-up visit with Resident #74, the wheelchair remained heavily soiled.On 11/21/2025, at 9:23 AM, the surveyor interviewed the Housekeeper/Maintenance staff member (HKM), who stated that two (2) days per week, the wheelchairs were taken apart and cleaned. He further stated that at the time of cleaning, the wheelchairs were checked to ensure that they were intact and in proper working condition. On 11/21/2025 at 9:32 AM, the surveyor interviewed the DESM, who stated that the wheelchairs should be cleaned every 2 weeks or as needed. He further noted that the wheelchairs should be kept clean and in good working condition.On 11/21/2025 at 10:12 AM, the surveyor interviewed the Director of Nursing (DON), who stated that wheelchairs and seat cushions should be kept clean, and in good repair. She further stated that if a seat cushion was torn or ripped, the Therapy department should be notified so that the seat cushion could be replaced by the facility.On 11/21/2025 at 11:15 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that there was a monthly wheelchair cleaning schedule posted on each unit. He further stated that wheelchairs should be cleaned as scheduled and as needed. The LNHA stated that the wheelchairs should be clean, safe, and functioning properly.On 11/24/2025, the surveyor conducted an environmental tour and observed the following:At 8:45 AM, Resident #5 was observed in the hallway of the C/D Unit, seated in a wheelchair. The wheelchair frame was rusty and contained a large buildup of dirt, dust, and residue on the frame and wheels. At that time, the resident stated, Look at this, I need a new seat, it's ripped. The surveyor observed a big rip on the right side of the seat of the wheelchair.At 8:51 AM, Resident #15 was observed in the hall near the activity area, seated in a wheelchair. The wheelchair contained rust, a buildup of dust, and residue.At 8:54 AM, Resident #29 was observed near the activity room, seated in a wheelchair. The wheelchair was rusty in multiple areas on the frame. Dust was also noted on the wheels and frame. At that time, Resident #29 stated that they cleaned the wheelchair themselves.At 9:01 AM, Resident #37 was observed in the activity area, seated in their wheelchair. The wheelchair was noted with a buildup of dust and dirt on various areas of the frame.At 9:07 AM, Resident #52 was observed in the activity area, seated in their wheelchair. The wheelchair was noted with a large amount of residue buildup on the frame. At that time, Resident #52 stated that their wheelchair was cleaned approximately every six (6) months by the facility.At 9:12 AM, Resident #50 was observed seated in their wheelchair. The wheelchair was noted with a buildup of residue on the frame. At that time, Resident #50 stated that they could not recall the last time their wheelchair was cleaned by the facility.At 9:16 AM, the surveyor was joined by the Director of Environmental Services and Maintenance (DESM) on the tour, and he confirmed the findings. He stated that he was disappointed in the condition of the wheelchairs because an employee was scheduled to work 2 days per week to clean them.At 9:18 AM, Resident #56 was observed in the activity room, seated in their wheelchair. The wheelchair was noted with a significant amount of residue buildup on the frame. At that time, the resident stated that they could not recall the last time their wheelchair was cleaned by the facility.At 9:35 AM, Resident #79 was observed seated in their wheelchair. The wheelchair had a large buildup of rust and residue on the frame.At 1:20 PM, the surveyor made a follow-up visit with Resident #5, as the surveyor was exiting the resident's room, an over-the-toilet commode was noted with rust on the legs and arms. On 11/24/2025 at 12:48 AM, the surveyor interviewed the Regional Nurse/Infection Preventionist (RN/IP), who stated that the wheelchairs should be cleaned every 2 weeks and as needed. She further stated that it was important that wheelchairs were cleaned so the residents did not get sick and develop health concerns and spread viruses.A review of the wheelchair cleaning schedule for July, August, September, October, and November 2025 revealed that each wheelchair was scheduled for cleaning once per month.A review of the facility's policy, Wheelchair 2025, undated, included, Wheelchair cleaning and sanitation requirements. A monthly wheelchair cleaning schedule is posted at each nurse's station for your reference. All resident wheelchairs must be: Thoroughly cleaned and sanitized twice per month (every other week). Cleaned according to the posted schedule for each unit. Fully wiped down, including arm rests, seat cushions, back supports, frames, footrests, wheels, and push handles using facility -approved disinfectants. Inspected during cleaning for any signs of damage, loose parts, unsafe wheels, or malfunctioning brakes.Proper wheelchair cleaning is an important part of resident safety, infection control, and daily comfort. All staff are expected to follow the posted schedule and complete all required documentation after each cleaning. NJAC 8:39-31.4 (a)

Based on interview and record review, it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS), a periodic and federally mandated standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 10 residents (Resident #6) reviewed for Resident Assessment and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. At a minimum, facilities are required to complete a comprehensive assessment for each resident within 14 calendar days after admission to the facility, when there is a significant change in the resident's status and not less than once every 12 months while a resident, where 12 months refers to a period within 366 days. A review of Resident #6's electronic medical record revealed the following: Resident # 6: The Significant Change in Status- Comprehensive MDS ARD was dated 10/6/25 and was not completed until 11/19/25. On 11/24/25 at 10:41 AM, the surveyor conducted a telephone interview with the MDS Coordinator (MDSC) who stated that she was the only MDSC for two (2) buildings and that she was out sick during that timeframe with no other employee covering for her. The MDSC further stated that she would send a list of residents whose MDS assessments were due to the facility and once completed, a Registered Nurse (RN) such as the Director of Nursing (DON) or Regional Nurse/Infection Preventionist (RN/IP) would sign the assessments prior to transmitting them to the Centers for Medicare and Medicaid Services (CMS). The MDSC confirmed that Resident #6's Significant Change MDS was completed after the required date. On 1/24/25 at 11:59 AM, the surveyor interviewed the DON who stated that the RN/IP signed the completed assessments prior to submission to CMS. The DON further stated that she would expect the MDS to be completed in a timely fashion within the timeframe. On 11/24/25 at 12:05 PM, the surveyor interviewed the RN/IP who stated that the MDSC would normally send her a schedule of the residents' ARDs and when the MDS needed to be completed. She further stated that since the MDSC was a Licensed Practical Nurse (LPN), the RN/IP would sign the completed assessments prior to transmitting to CMS. The RN/IP stated it was important to complete the MDS assessments as scheduled to capture an accurate assessment of the resident. On 11/25/25 at 10:12 AM, in the presence of the survey team, the DON and the Licensed Nursing Home Administrator (LNHA) acknowledged that the MDS assessment for Resident #6 was completed late. A review of facility's MDS 3.0 Completion policy, implemented 10/25/25, reflected: d. Significant Change in Status Assessment (SCSA) -a comprehensive assessment completed within 14 days of the identification of status change that meets the requirements outlined in Chapter 2 of the Version 3.0 RAI manual. NJAC 8:39-11.2 (e)

Based on interview and record review, it was determined that the facility failed to complete the Quarterly Minimum Data Set (MDS), a periodic and federally mandated standardized assessment tool, within the required timeframe. This deficient practice was identified for 4 of 10 residents (Resident #5, #12, #18, and #35) reviewed for Resident Assessment and was evidenced by the following:Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). The Assessment Reference Date (ARD) of the Quarterly MDS was within 92 days after the ARD of the previous MDS and 2). the completion date was no later than 14 days after the ARD. The following resident records were identified to be deficient with completion dates: 1.Resident #5: The Quarterly MDS ARD of 10/5/25 was completed on 11/19/25 and accepted on 11/19/25. 2. Resident #12: The Quarterly MDS ARD of 10/14/25 was completed on 11/19/25 and accepted on 11/19/25. 3. Resident #18: The Quarterly MDS ARD of 10/7/25 was completed on 11/19/25 and accepted on 11/19/25. 4. Resident #35: The Quarterly MDS ARD of 10/13/25 was completed on 11/19/25 and accepted on 11/19/25. On 11/24/25 at 10:41 AM, the surveyor conducted a telephone interview with the MDS Coordinator (MDSC) who stated that she was the only MDSC for two (2) buildings and she was out sick during that time with no other employee covering for her. The MDSC further stated that she would normally send a list of residents whose MDS assessments were due to the facility and once completed, a Registered Nurse (RN), such as the Director of Nursing (DON) or Regional Nurse/Infection Preventionist (RN/IP) would sign the assessments, then transmit them to the Centers for Medicare Services (CMS). The MDSC confirmed that Residents #5, #12, #18, and #35's Quarterly MDS were completed late. On 11/24/25 at 11:59 AM, the surveyor interviewed the DON who stated that the RN/IP signed the completed assessments prior to submission to CMS. The DON further stated that she would expect the MDS to be completed in a timely fashion within the timeframe. On 11/24/25 at 12:05 PM, the surveyor interviewed the RN/IP who stated that the MDSC would send her a schedule of the resident ARDs and when the MDS needed to be completed. She further stated that since the MDSC was a Licensed Practical Nurse (LPN), the RN/IP would sign the completed assessments prior to transmitting to CMS. The RN/IP stated it was important to complete the MDS assessments as scheduled to capture an accurate assessment of the resident. On 11/25/25 at 10:12 AM, in the presence of the survey team, the DON and the Licensed Nursing Home Administrator (LNHA) acknowledged that the Quarterly MDS assessments were completed late. A review of the facility's MDS 3.0 Completion policy, implemented 10/25/25, reflected e. Quarterly Assessments-completed using the ARD no > 92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD). N.J.A.C. 8:39-11.2

Based on interview and record review, it was determined that the facility failed to transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 4 of 10 residents reviewed for resident assessment (Resident #2, #4, #8 and #11). This deficient practice was evidenced by: The MDS is a comprehensive federal mandated process for clinical assessment of all residents that must be completed and submitted to the Quality Measure System. The facility must electronically transmit the MDS no later than 14 days of assessment completion. After transmitting the MDS a quality measure is generated to enable a facility to monitor a resident's decline and progress. The following residents were identified as having late assessment completions: 1.Resident #2: the Quarterly MDS was completed on 9/15/25 and was transmitted and accepted on 11/19/25.2.Resident #4: the Annual MDS was completed on 9/15/25 and was transmitted and accepted on 10/19/25.3.Resident #8: the Quarterly MDS was completed on 9/15/25 and was transmitted and accepted on 11/19/25.4.Resident #11: the Quarterly MDS was completed on 9/22/25 and was transmitted and accepted on 11/19/25. On 1/24/25 at 10:41 AM, the surveyor conducted a telephone interview with the MDS Coordinator (MDSC) who stated that she was the only MDSC for two (2) buildings and she was out sick during that time, and no other employee was covering her. The MDSC further stated that the MDS assessments should be transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days after completion. The MDSC confirmed that Resident # 2, #4, #8 and #11's completed MDS assessments were transmitted late. On 11/24/25 at 11:59 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she would expect the MDS be completed in a timely fashion and transmitted within the timeframe. On 11/24/25 at 12:05 PM, the surveyor interviewed the RN/IP who stated that the MDSC would send her a schedule of the residents ARDs and when the MDS assessments needed to be completed. She further stated that the since the MDSC was a Licensed Practical Nurse (LPN), the RN/IP would sign the completed assessments prior to transmitting to CMS. The RN/IP stated that she would expect the MDS assessments would be completed and transmitted within the timeframe. On 11/25/25 at 10:12 AM, in the presence of the survey team, the DON and the Licensed Nursing Home Administrator (LNHA) acknowledged that the MDS assessments were transmitted to CMS late. A review of facility's MDS 3.0 Completion policy, implemented 10/25/25, reflected under 7. Transmission Assessments- all assessments shall be transmitted to the designated CMS system (name redacted) within 14 days of completion all assessments. NJAC 8:39-11.2

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: accurately account for and document the administration of controlled medications. This deficient practice was identified on 1 of 2 medication carts reviewed for medication storage, and was evidenced by the following:During medication storage review on 11/21/25 at 11:10 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1), reviewed the C/D unit long hall nursing unit's medication cart's which revealed the following: the individual resident Controlled Drug Record log (declining inventory log) for Resident #29 indicated the 9:00 AM (9 AM) dose of pregabalin (a controlled medication used to treat pain) 100 milligram (mg) tablet was not signed out on the declining inventory log. The declining inventory log was missing Nursing Administering signatures for 11/21/25 9 AM dose. A further review revealed that the individual resident Controlled Drug Record log for Resident #23 indicated the 9:00 AM (9 AM) dose of lacosamide oral tablet 200 mg (a controlled substance used to treat seizures) was not signed out on the declining inventory log. The declining inventory log was missing Nursing Administering signatures for 11/21/25, 9 AM dose. At the time of observation, the surveyor interviewed LPN #1, who stated she administered the 9 AM dose of pregabalin that morning (11/21/25) but did not sign the declining inventory log for Resident #29. She further stated that she administered the 9 AM dose of lacosamide that morning but did not sign the declining inventory log for Resident #23. LPN # 1 confirmed that the 9 AM dose was signed out as being administered in the electronic Medication Administration Record (eMAR) but was not accounted for on the declining inventory log. LPN #1 further acknowledged that declining inventory logs should be completed upon dispensing the medication to keep track of the narcotic count. LPN #1 indicated the importance of signing the declining inventory log is to ensure resident safety, ensure the medication was not given twice, and to keep the medication count correct. On 11/21/25 at 11:25 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) on unit C/D, who stated that she expected the nurse who was administering medications to sign the narcotic (controlled substance) declining inventory log when they pop it out of the bingo card. On 11/24/25 at 1:03 PM, the surveyor interviewed the Director of Nursing (DON), who stated nurses were to sign the declining inventory log as soon as it was taken from the medication cart to administer to the resident. She further stated that the importance of signing the declining inventory log was to avoid drug diversion and to ensure the resident received the medication as ordered. On 11/25/25 at 10:09 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, acknowledged that the declining inventory logs should be completed and filled out for each narcotic dose dispensed immediately at the time the medication was removed from inventory. She further stated there should not be any blanks on the narcotic declining inventory logs. A review of the facility's Medication Administration policy with a revision date 1/3/25, included.medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.if medication is a controlled substance, sign narcotic book. NJAC 8:39-29.4, 29.7(c)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to a). remove unwanted medication from the resident's bedside table (Resident #27), and b). properly secure medication within the medication cart for 1 of 2 nurses observed during the medication administration pass. This deficient practice was evidenced by the following: 1.) On 11/20/2025 at 8:16 AM, the surveyor observed Licensed Practical Nurse (LPN) #2 prepare medications for Resident #27, which included polyethylene glycol 3350 powder (used to treat constipation) 17 grams mixed with eight (8) ounces of water, and fluticasone-salmeterol 250-50 micrograms/actuation (MCG/ACT) aerosol powder inhaler (used to treat chronic obstructive pulmonary disease). LPN #2 then locked the medication cart and took the medications into the resident's room. Resident #27 took two swallows of the water containing the polyethylene glycol, then placed the cup on the overbed bedside table and stated that they did not want the remainder of the medication. The LPN encouraged the resident to finish the rest of the medication, however, the resident asserted that they would be throwing the medication away because they did not want it. The LPN then walked out of the resident's room with the resident's breakfast tray and inhaler in her hands. LPN #2 left the cup of water containing the polyethylene glycol on the resident's overbed bedside table. At that time, the surveyor interviewed LPN #2, who insisted that the resident would eventually drink the polythene glycol, and that she would periodically check back with the resident to see if the cup was empty. When asked if medications could be left on a resident's bedside table, the LPN #2 stated that she did not leave pills at the bedside. The surveyor continued to interview LPN #2 who stated, yes, polyethylene glycol was considered a medication. LPN #2 then went back into the resident's room, removed the medication from the overbed table, discarded it and LPN #2 then returned to the medication Cart. 2.) On 11/20/25 during the medication administration task with LPN #2, the surveyor noted that two blister pill packs (a form of pharmaceutical packaging that organizes medications into individual, sealed compartments) of Lisinopril 10 milligrams (mg - used to treat high blood pressure) that belonged to another resident (Resident #1) was left unattended on top of the medication cart while LPN #2 was in Resident #27's room administering their medication. One (1) blister pack contained eight (8) tablets of Lisinopril, and the other blister pack contained 1 tablet. Immediately upon the discovery, the surveyor interviewed LPN #2 who stated that when she administered Resident #1's medications earlier that morning, she realized that the Lisinopril was discontinued, so she removed the two blister packs from the medication cart drawer and placed them on top of the cart, where they remained, so that she could remember to get rid of them. She further stated that all medications should be secured when the nurse was away from the medication cart. On 11/20/2025 at 11:49 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #2, who stated that medications should never be left at the resident's bedside. She further stated that if a resident refused their medication, it should be discarded immediately. LPN/UM #2 also stated that medications should be kept secured within the medication cart or medication room and should never be left unattended on the medication cart, because other residents could have access to it. On 11/21/2025 at 10:15 AM, the surveyor interviewed the Director of Nursing (DON), who stated that during medication administration, the nurse should stay with the resident to ensure that all the medications were swallowed, and it should never be left at the bedside. She further stated that another resident could go into the resident's room and take the medication. The DON also stated that medications should be locked when the medication cart was out of sight because the medicine could become a danger to wandering residents. A review of the facility's Medication Storage policy, dated 10/10/24, included, .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. NJAC 8:39-29.4(h)

Based on interview and review of facility documents, it was determined that the facility failed to ensure that a Certified Nursing Assistant (CNA) received at least 12 hours of mandatory in-service training annually for 1 of 5 CNAs reviewed (CNA #1). The deficient practice was evidenced by the following:On 11/24/25, at 11:00 AM, the surveyor reviewed the provided in-service education for five (5) randomly selected CNAs for the years 2024 and 2025, which revealed the following: CNA #1, with a date of hire of 6/30/15, had 9.25 hours of in-service training from date of hire anniversary dates (June 2024 - June 2025). On 11/25/25 at 10:00 AM, the surveyor interviewed the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team. The DON stated she was responsible for the CNA in-service training and that it was important for CNAs to complete 12 hours of education annually to ensure the CNAs know how to properly care for the facility's residents. At that time, the DON confirmed that CNA #1 did not meet requirement for 12 hours of education from date of hire anniversary date, nor did the CNA meet the requirements for the 2024 calendar year. A review of the facility's policy, Required Training, Certification and Continuing Education of Nurse Aides, dated 5/1/25, included, The facility will provide at least 12 hours of in-service training annually. Further review of the policy revealed, Documentation of the in-services will be maintained in the employee's personnel file, and It is the responsibility of the employee to attend required in-service trainings to maintain employment status with the facility. N.J.A.C. 8:39-43.17(b)

Based on interview and document review it was determined that the facility failed to ensure a Surety Bond was in place to provide coverage to protect resident personal needs account funds held by the facility. The deficient practice effected all residents who had personal needs funds held by the facility and was evidence by the following: On 06/13/24 at 2:00 PM. and again on 06/14/24 at 9:00 AM, the surveyor requested a facility Surety Bond from the Liscensed Nursing Home Administrator (LNHA). On 06/14/24 at 9:30 AM, the LNHA provided a Funds Balance Report for 06/03/24 which listed 48 active residents with a combined balance of $20,829.05. The surveyor again requested a Surety Bond from the LNHA. On 06/14/24 at 12:20 PM, the LNHA provided a Commercial Crime Policy effective: July 24, 2023- July 24, 2024, for a Bond Limit: $90,000. The policy did not specify any coverage to secure resident funds. On 06/14/24 at 11:37 AM, during an interview with the LNHA, in the presence of four surveyors, the LNHA provided a copy of a surety bond, effective June 14, 2024 for $100,000. The surveyor inquired to the LNHA why the surety bond was effective the same day and the LNHA stated he told the new business office that he needed the surety bond as soon as possible and he was provided the copy on June 14, 2024 and the surety bond was effective the same day. The surveyor requested the prior surety bond. On 06/17/24 at 9:12 AM, the LNHA provided a copy of a Certificate of Property Insurance, dated 06/14/24. The document revealed the Type of Policy: Crime, Limits: $90,000. The LNHA then stated that was the surety bond policy. On 06/17/24 at 11:01 AM, the Director of Nursing provided the Surety Bond Requirements, Policy dated 11/01/23. The Policy Explanation and Compliance Guidelines: revealed 1. The facility must be able to show proof that it has a surety bond, or another alternative to a surety bond, a crime policy etc. 3. Reasonable alternatives to a surety bond must: a. Designate the oblige (depending on State law, the resident individually or in aggregate, or the Stte on behalf of each resident) who can collect in case of a loss; B. Specify that the oblige may collect due to any failure by the facility, when by omission, bankruptcy, or omission, to hold, safeguard,, manage, and account for the residents' funds; and ac. Be managed by a third party unrelated in any way to the facility or its management. 4. Self insurance is not an acceptable alternative to a surety bond. On 06/19/24 at 1:39 PM, during the exit conference, the surveyor asked the LNHA why the surety bond was effective after surveyor inquiry. The LNHA stated, he cannot speak to the old owners, and did not respond as to why the bond was not in place prior to surveyor inquiry. The facility had no additional information to provide. NJAC 8:39-9.5(d)1

Based on interview and review of Nursing Staffing Report sheets, Payroll Based Journal (PBJ) Reports and facility provided documents, it was determined that the facility failed to ensure the Director of Nursing served as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents for 7 of 16 days reviewed The deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for 05/07/2023 through 05/13/2023 revealed the facility had one RN for the day shift on 05/12/2023. On 05/12/2023, the census was 100 residents. A review of the Nurse Staffing Reports completed by the facility for 05/26/2024 through 06/01/2024 revealed the facility had one RN for the day shift on 05/26/2024 and 05/27/2024. On 05/26/2024, the census was 92 residents. On 05/27/2024, the census was was 91 residents. A review of the Nurse Staffing Reports completed by the facility for 06/02/2024 through 06/08/2024, revealed the facility had one RN for the day shift on 06/08/2024. On 06/08/2024. the census was 90 residents. On 06/17/2024 at 1:24 PM, during an interview with the surveyor, the Human Resource Director told the surveyor that the Director of Nursing (DON) worked the specified days above as the Registered Nurse. At that time, the surveyor requested time sheets that show when the DON arrived to the facility. At that time, the Human Resource Director stated that the DON is a salaried employee and does not record the time of arrival to the facility. On the same date at 2:05 PM, the surveyor received an email from the Human Resource Director titled, RN Coverage Schedule. The email contained an attached document with the heading, The following RN rotation coverage for May 2024-June 2024 is completed by Salaried RN's. The email showed the that the dates mentioned above were covered by the DON. On 06/18/2024 at 9:59, AM during an interview with the DON, the surveyor asked, How were you acting as the RN when you are DON and had census over sixty residents. The DON replied, we had a weekend supervisor and she quit. We had to implement something for the time being. A review of the Payroll Based Journal (PBJ) Report for fiscal year quarter 2, 2024 (January - March) revealed that the facility triggered for no RN (Registered Nurse) hours. The infraction dates, as reported by the facility were: 01/27/2024 01/28/2024 02/24/2024 02/25/2024 03/10/2024 03/23/2024 03/23/2024 Upon request of the census and employees who worked those days, it was determined that the facility's previous Director of Nursing, as identified by the [NAME] President of Clinical Services (VPCS), worked as the only RN on the following days: 02/24/2024 02/25/2024 03/10/2024 The resident census was provided to the surveyor through email from the VPCS. The resident census on 02/24/2024 was 96. The resident census on 02/25/2024 was 95, and the resident census on 03/10/2024 was 92. On 06/19/2024 at 11:13 AM during an interview with the surveyor, The VPCS replied, I'm not quite sure. I'd have to look back at that. when the surveyor asked what was the reason the DON worked as the facility's only Registered Nurse on days when the daily census was over 60. On 06/19/2024 at 1:39 PM during an interview with the surveyor, the DON told the surveyor she became the DON in April, 2024. A review of the facility-provided policy titled, Nursing Services-Registered Nurse (RN) with an implemented date of 11/14/23 revealed but was not limited to, 1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week. NJAC 8:39-25.2(h)

Based on interview and review of facility documents, it was determined that the facility failed to provide Certified Nurse Aides (CNA) regular in-service education based on the outcome of employee job performance appraisals. The deficient practice was identified for 3 of 10 CNAs reviewed. The deficient practice was evidenced by the following: A review of the facility provided documents titled, Employee Job Performance Appraisals revealed eleven measurable attributes such as but not limited to, Job Expectations, Adaptability, Leadership, and Dependability. Each attribute also has a comments section and a goal section. Each attribute can be scored with a numeral revealing the following: 0 - Fails to Meet Expectations 1 - Needs Immediate Improvement 2 - Meets Expectations 3 - Above Average 4 - Excellent A review of CNA # 1's Employee Job Performance Appraisal revealed a score of 1 under Adaptability. Number 1 indicated, Needs Immediate Improvement. The comments and goal section were left blank. On the reverse side of the document under Leadership, the score was 1. The comments and goal section was left blank. Further, under Dependability, the score was 1 and a hand written note revealed that CNA # 1, Requires to improve attendance call outs. The document was signed by the employee on 9/11/2023. A review of CNA # 2's Employee Job Performance Appraisal document revealed a score of 1 under Leadership. A handwritten note revealed, Area requires improvement. The document was signed by the employee but no date was indicated. A review of CNA # 3's Employee Job Performance Appraisal document revealed a score of 1 under Adaptability. A handwritten note revealed, Improve Attendance. The document was signed by the employee on 6/19/2023. On 06/18/2024 at 9:59 AM, during an interview with the Director of Nursing (DON), the surveyor asked how an area that needs immediate improvement can be left blank. The DON stated, not that it's supposed to happen but we go case by case. The DON then stated, No when the surveyor asked if she was ever trained on completing employee appraisals. The DON said that at the time of the appraisal, the employee signed the document and the concerns were verbally discussed with them. Lastly, the DON confirmed the document was blank stating, I provided what I had. On 06/19/2024 at 9:21 AM, the DON informed the surveyor that the facility does not have a policy on Employee Job Performance Appraisal and that it was at DON discretion. On 06/19/2024 at 11:13 AM, during an interview with the surveyor, the [NAME] President of Clinical Services (VPCS) interim infection preventionist replied, No, when the surveyor asked if the comments and goal section should be left blank. The VPCS replied I'd have to look at specific case. when the surveyor asked if employees who scored a one or zero receive education based on the outcome of the review. The surveyor asked how should the in-service be documented. The VPCS replied, We do education with them and they would have to sign the education. The surveyor then asked if someone scored poorly, what would be the procedure from that point. The VPCS replied, They would receive an education and they would have to sign it. On the same date at 1:39 PM, the VPCS confirmed the facility did not have a policy on Performance Evaluations. A review of the Facility Assessment titled, revealed under section, J. but not limited to, Training/education and competencies/skill checks are generally provided upon hire, during monthly in-servicing/training, annual in-servicing/training, whenever an area of concern is identified, new areas or new situations/developments evolved are identified based on resident diagnoses and/or clinical condition. The document further revealed, Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. A review of the facility-provided document titled, Director of Nursing-Job Description revealed under, Major Duties and Responsibilities that the DON, Interprets and communicates policies and procedures to nursing staff, and monitors staff practices and implementation. The document also revealed that the DON, Evaluates work performance of all nursing personnel and implements discipline according to operational policies. Lastly, the documented revealed, Individual performance will be evaluated using the following scale: 1. Unsatisfactory: Achieves results which are far less than the standards identified for performance factors rated. 2. Needs Improvement: Achieves results which are less than the standards identified for the performance factors rates. Exhibits the potential to become a competent performer. May be new to job or need skill development. N.J.A.C. 8:39-43.17

Based on observation, interviews, and other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by: On 06/13/24 between 09:24 AM until 10:01 AM, the surveyor observed the following in the kitchen in the presence of the Dietary Manager (DM): 1. On 06/13/24 at 9:25 AM, the surveyor observed a Dietary Aid (DA) preparing food during the initial tour of the kitchen and was noted not wearing a beard guard. The DM stated that all staff have been trained according to the policy and procedure of the kitchen to wear proper attire while working in the kitchen. He confirmed that all staff must wear a hairnet and beard guard to prevent food contamination. The DA left the workstation and walked towards the entrance to put on his beard guard. 2. On 06/13/24 at 9:27 AM, the surveyor observed an opened package of hot dog buns containing 3 buns left in the package that was not dated with an opened date and use by date. The DM stated that items need to be dated when they are opened and dated with a use by date according to the facility policy. 3. On 06/13/24 at 9:35 AM, the surveyor observed 6 lbs (pound) can of diced potatoes in the dry storage area with a 2 inch dent located on the seam of the can. The DM confirmed that the canned diced potatoes should not be used and was removed. 4. On 06/13/24 at 9:40 AM, the surveyor observed dried spiced goods in the food preparation line that did not contain a date when the spices were opened, nor did it contain a use by date. These items consisted of grated cheese, adobo seasoning, paprika, black pepper, onion power and cinnamon. 5. On 06/13/24 at 9:43 AM, the surveyor observed 10 prepared salami sandwiches in the walk-in refrigerator. Only 1 out of 10 salami sandwiches had the prepared date labeled, and 10 out of 10 did not have a use by date. The DM stated once the sandwiches were prepared, they were good for 3 days. The DM confirmed that all food items should have a date of preparation and use by date labeled. 6. On 06/13/24 at 9:46 AM, the surveyor observed 15 dessert cups of diced pineapple on a tray in the walk-in refrigerator. Only 1 out of 15 pineapple cups had a prepared date labeled, and 15 out of 15 did not have a use by date. 7. On 06/13/24 at 9:48 AM, the surveyor observed 3 pitchers that contained dark liquid in the walk-in refrigerator, that the DM verified was iced tea. The 3 pitchers of iced tea were not labeled with a preparation date and use by date. 8. On 06/13/24 at 9:50 AM, the surveyor observed a plate of leftover cheese ravioli with tomato sauce covered with a clear food service film in the walk-in refrigerator. The cheese ravioli was not labeled with a preparation date and use by date. 9. On 06/13/24 at 9:57 AM, the surveyor observed left over sauteed spinach in a stainless-steel pan covered with a clear food service film in the walk-in refrigerator. The sauteed spinach was not labeled with a preparation date and use by date. The surveyor reviewed the facility provided policy titled Food Safety and Sanitation. The policy revealed the following: 2. Employees All staff will be in good health, will have clean personal habits and will use safe food handling practices. Hair restraints are required and should cover all hair on the head. Beard nets are required when facial hair is visible. 3. Food Purchasing Bulging or leaking cans, cans with severe dents on the seams, or broken containers of food will not be used. 4. Food Storage All time and temperature control for safety foods (including leftovers) should be labeled, covered, and dated when stored. When a food package is opened, the food item should be marked to indicate the open date. This is used to determine when to discard the food. Leftovers are used within 72 hours (or discarded) NJAC 8:39-17.2 (g)

Based on observation, interview and document review it was determined that the Licensed Nursing Home Administrator failed to ensure that facility policies and procedures were developed and consistently implemented. This failure to ensure a system was in place for residents who smoked independently and held their own smoking material and lighter, had the potential to effect all residents on 3 of 3 resident units and was evidenced by the following: On 06/13/24 at 2:03 PM, three surveyors observed a person walking behind the building on a path by the woods. The surveyors approached the person, who was by him/herself, to interview them, while the person was headed toward the road and then turned toward the parking lot. The person identified him/herself as Resident #25 and stated that he/she lived at the facility. The surveyors accompanied Resident #25 for the duration of the walk throughout the parking lot and into the main entrance and then asked the Receptionst about the resident walking around the building. The Receptionist stated, Resident #25 signed the paper that if anything happened to him/her that we are not responsible and handed the surveyor a List of residents signed release of responsibility papers that contained nine names. On 06/14/24 at 10:00 AM, the surveyor interviewed the Director of Nursing (DON) regarding the list of residents that signed the paper and asked about the paper related to Resident #25. The DON stated residents can walk around the building, and yes it is a paper, we created a paper. The DON stated that she and the old administrator made up the paper. The DON was the assistant director of nursing at that time. The surveyor requested the paper. The DON provided a copy of the paper which revealed: I, [Signed by Resident #25] am alert and capable of making my own decisions. It is my wish to be allowed to come and go in and out of this facility freely and at my own will and risk. I understand hat this is against the advice and policy of [facility name redacted] and it's staff and doctors. By signing this document I hereby release [facility name redacted] and all its employees, mangers and management companies of any responsibilities of injuries I might sustain while out of the building. This shall include leaving the building and moving about in the parking lot or the entire area outside of the building. Signed by Resident #25, dated 07/25/23. The document also revealed: We hereby attest to the fact that [Resident #25] is alert and oriented and capable of making their own decisions. Signed by the current DON, dated 07/25/23 and [Doctor], 07/28/23. On 06/14/24 at 11:50 AM, five surveyors were in the conference room and observed Resident #25 walk past the back of the building by the Sub Acute area bordering the woods, was on a path and was also observed smoking a cigarette. At that time, the surveyor reviewed the electronic Medical Record (EMR) for Resident #25 which revealed the following: The Admission Record revealed diagnoses including Ecephalopathy, Unspecified (broad term for brain disease), Major Depressive Disorder, recurrent severe without psychotic features and hemilplegia and hemiparesis unspecified cerebrovscular disease affecting unspecified side. A Quarterly Mimimum data set dated [DATE] revealed the resident scored a 15/15 on the Brief Interview for Mental Status which indicated the resident was cognitively intact. Section GG, section K revealed the resident required supervision or touching assistance to walk 150 feet in a corridor or similar space. Section J1300 Tobacco use was left blank, neither yes or know was checked. The Current nine page Care Plan included the following Focus areas: Anticoagulant, Falls, Psychotropic Medicaiton, Pain, Altered Sleep Pattern, Smoking, ADL, Nursing non-compliance with daily clothing changes, showers and skin checks. and Activities. The Focus for Smoking revealed: Resident is a smoker and is at risk for injury. Resident is an independent smoker and does not require direct supervision to smoke. Date Initiated: 05/27/2024 Revision on: 05/27/2024 Goal: -Resident will abide by facility's smoking policy and remain safe during smoking times through the next review. Date Initiated: 05/27/2024 Revision on: 06/13/2024 Target Date: 10/15/2024 - Resident will smoke in designated areas without occurrence of injury through the next review. Date Initiated: 05/27/2024 Revision on: 06/13/2024 Target Date: 10/15/2024 Interventions - Perform smoking assessment according to facility policy. Date Initiated: 05/27/2024 - Educate resident on smoking policy. Date Initiated: 05/27/2024 - INDEPENDENT SMOKER: Resident is an independent smoker and does not require the use of a smoking apron or direct staff supervision during smoking breaks. Date Initiated: 05/27/2024. The Care Plan did not indicate the resident was able to hold own smoking material and lighters and walk around the building smoking. The Falls Care Plan Date Initiated: 05/08/24 The resident will be free from falls and subsequent injuries through the review date. Date Initiated: 05/18/2024 Revision on: 06/13/2024 Target Date: 10/15/2024 Resident's call light is within reach Date Initiated: 05/08/2024. There was no Care Plan related to the document that the resident signed, the ability to hold a lighter and cigarettes and smoke at will around the building perimeter. Resident #25's most recent smoking assessment, dated 02/12/24 revealed #3 Is resident physically capable of holding a cigarette, matches/lighter, and lighting and extinguishing own cigarette without assistance; yes; 9. Has resident been instructed in facility policy regarding safety of himself/herself or others; yes; 10. Has resident signed the [Facility Name] smoking agreement and smoker release of responsibility form, yes. On 06/14/24 at 11:58 AM, a surveyor observed Resident #25 entering the building from the main entrance. The surveyor inquired as to what the resident did outside and the Resident stated was outside walking the perimeter of the building and was smoking. Resident #25 stated he/she smoked a pack of cigarettes a day and stated kept a personal lighter to light his/her own cigarettes. On 06/18/24 at 11:33 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team regarding what was his responsibilities. The LNHA stated he was responsible for the oversight and care of all residents and all regulations in accordance with state and federal law since he had been hired on 12/3/23. The surveyor asked if he ensured policies were followed and he stated, yes, and the surveyor asked if that included the smoking policy and he stated yes. The surveyor asked how he would ensure that, the LNHA stated through meeting, daily rounds, and walked through all three units, including the kitchen, maintenance shop and laundry. The surveyor asked the LNHA if the smoking policy would allow residents held their own lighters to light there own cigarettes. The LNHA stated,we don't allow them to have lighters. The surveyor asked why not, and the LNHA responded, forsafety. The surveyor asked if a resident chose to not follow the policy what would happen, and the LNHA stated, we educate them. The LNHA stated they are supposed to be smoking in the smoking area. The surveyor asked if residents were allowed to keep there own lighters and walk around the building smoking. The LNHA then stated there were a handful of residents that were able to do that and they signed a waiver. The LNHA stated they sign themselves to go out on the property and they are more independent of ADLs [activities of daily living]. The LNHA, then stated some light there own cigarettes outside and they know they need to smoke 25 feet away from the building. The surveyor asked how he would know that and he stated, it's a building policy. The surveyor showed the LNHA the document signed by Resident #25 and asked where the document came from and was it a legal document. The LNHA stated he was not sure who made it up, and I did not say it was legal. The surveyor asked what the policy was for use of the document and the LNHA stated, I would have to check. The surveyor asked if the resident could hold onto their own lighters and keep them with them. The LNHA stated, my original answer was for those residents that were in the designated smoking area and he was not sure if there was a policy and stated independent residents had their own lighters. The surveyor showed the LNHA the document again and also showed him the list of residents that signed responsibility papers and asked what the documents were for since the documents did not have smoking listed. The LNHA stated it was a release of responsibility of their own risk and the residents can be independent outside of the building and facility would not be responsible. The surveyor asked about a policy for residents who hold their own lighters inside the facility, come and go as they wish to smoke around the facility. The LNHA stated he doesn't know, I have to check and not sure if there was a policy and would go check. On 06/18/24 at 11:55 PM, the LNHA returned and stated, there was no specific policy for residents who smoked outside and there was no policy for the use of the waiver. The LNHA stated the smoking policy only was for the residents that smoked in the designated areas. The surveyor asked how do you protect other residents from gaining access to the lighter, and asked how many residents hold their own lighters, and the LNHA did not respond. The surveyor informed the LNHA about the observations of Resident #25 smoking around the facility. The LNHA confirmed he was aware. The surveyor asked if there was a policy to prevent other residents from gaining access to the lighters and the LNHA stated, I do not have an answer for that. On 06/18/24 at 12:26 PM, the surveyor interviewed the facility Social Worker (SW) regarding the document Resident #25 signed. The SW stated the paper was for the residents who leave independently and so the resident can go to the store. The SW stated it was for the resident were pending Medicaid, but they they met criteria for residency in a long term care facility. The SW stated the paper allowed for people to go through the front door without somebody having to sign them out. A review of the Administrator signed job description, dated 12/23/23 revealed Position Purpose: Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to the residents. Major Duties and Responsibilities; Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. NJAC 8:39-9.2(a)

Based on interview and review of pertinent facility documents it was determined that the facility failed to submit accurate No RN [Registered Nurse] Hours Payroll Based Journal (PBJ) Report to the Centers of Medicare and Medicaid Services (CMS). The deficient practice was identified for 4 of 7 infraction dates on the PBJ Report for Fiscal Year Quarter 2 January 1 - March 31. A review of the PBJ Report for Fiscal Year Quarter 2 2024 January 1 - March 31 revealed the following days as ,Infraction Date under the No RN Hours Metric: 01/27 01/28 02/24 02/25 03/10 03/23 03/24 A review of the facility provided document titled, The Following RN rotation coverage revealed that on 01/27/2024 and 01/28/2024, the facility's current Director of Nursing worked as an RN. At that time, the DON was not promoted to the DON role. A review of the same document revealed that on 03/23/2024 and 03/24/2024 the [NAME] President of Clinical Services worked as the RN. On 06/19/2024 at 1:57 PM during an interview with the surveyor, the current DON revealed she became the DON sometime in April of 2024. A review of the facility policy titled, Nursing Services-Registered Nurse (RN) implemented on 11/14/23, revealed under Policy Explanation and Compliance Guidelines that, 3. The facility is responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Journal (PBJ) system. NJAC 8:39-41.1

Based on observation, interview and document review it was determined that the facility failed to ensure a resident room and the resident environment was free of insects, and that staff addressed a resident in a dignified manner. This deficient practice occurred for 1 of 20 residents reviewed (Resident #55) and was evidenced by the following: On 06/13/24 at 10:28 AM, Surveyor #1 observed Resident #55 in bed and there was a noticeable urine odor in the room and the resident's urinary catheter was lying on the bed. Resident #55 stated, he/she was waiting for coffee at that time and acknowledged there was an odor. Black flies were noted scattered throughout the room and when asked the resident about the flies, the resident confirmed he/she was aware of the flies. Resident #55 then stated the smell isn't from me. On 06/13/24 at 2:01 PM, Surveyor #1 and #2 observed the resident in bed on top of a pink bedspread, with the urine catheter also on the bed and the bed remote next to it. The surveyors observed two black flies on the bedspread, one on the remote and observed flying in the room. The surveyors requested the Licensed Practical Nurse Unit Manager (LPNUM) to accompany the surveyors to the room. The LPNUM stated Resident #55 was alert and oriented and was non-compliant with care. When asked the LPNUM about the flies and if having flies on the bed and in the room was okay, she stated, it is not okay, it is not clean. The LPNUM stated then stated she never saw the flies before. On 06/14/24 at 9:07 AM, Surveyor #2 observed black flies inside of Resident #55's room while resident was eating a meal. A black fly was on top of the burgundy meal tray lid that was on the bed next to the resident. Surveyor #2 requested the nurse (LPN #2) to come to the resident's room. The surveyor showed the nurse the flies and LPN #2 stated Resident #55 was very hard of hearing and he/she is a very noncompliant [gender redacted] and walked away from the surveyor and exited the room. Surveyor #2 interviewed LPN #2 at the nursing station about Resident #55 and the flies. LPN #2 stated, Resident #55 was a dirty old [gender redacted]. Surveyor #2 asked LPN #2 if that is what she called her residents and she stated he/she was set in his/her ways. On 06/14/24 at 10:08 AM, the Director of Nursing (DON) provided a Promoting/Maintaining Resident Dignity Policy, implemented 01/09/24 which revealed: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 10. Speak respectfully to residents; avoid discussions about residents that may be overheard. On 06/14/24 at 11:01 AM, Surveyor #2 in the presence of another surveyor interviewed the DON regarding the observations of flies and how LPN #2 spoke about Resident #55 at the nursing station as others walked by. Surveyor #2 then asked if what LPN #2 referred to the resident as was okay. The DON stated, no, that was not okay and stated that she heard about what happened and that the LPN #2 was trying to be cute and it was a dignity issue. On 06/17/24 at 10:35 AM, Surveyor #1 observed Resident #55 in bed, and the urinary catheter bag was observed on the floor and black flies were observed in the room. On 06/19/24 at 11:34 PM, the survey team held an exit conference with the DON, Infection Preventionist, and Licensensed Nursing Home Administrator to reviewed the above concerns. NJAC 8:39-4.1(11)(12)

Based on observation, interviews and record review, the facility failed to ensure Resident #12 preferences had been accommodated. This deficient practice occurred for 1 of 20 residents reviewed (Resident #12) for accommodation of needs and was evidenced by the following: During the initial tour on 6/14/24 at 10:31 AM, interview with Resident #12 revealed that would like to get out of the bed at a certain time and their wishes had not been honored. On 6/17/24 at 10:14 AM surveyor #2 followed up with Resident #12 regarding their concerns. The observation of Resident #12 revealed that Resident #12 was in bed dressed in a hospital gown. Resident #12 was upset and was crying to the surveyor and stated that he/she had not been able to contact their family. Resident #12 further stated that their belongings were still at the other facility and could not get in touch with the Social Worker (SW). When inquired if the resident enlisted the assistance of the SW at the current facility, Resident #12 stated, yes but nothing had been done. On 6/17/24 at 12:30 PM, the surveyor reviewed Resident #12 admission record. The admission face sheet reflected that Resident #12 had diagnoses which included but were not limited to; metabolic encephalopathy, difficulty in walking, weakness and morbid obesity. Review of the 2/16/24 Quarterly Minimum Data Set Assessment in the Electronic Medical Recort (EMR) for Resident #12 revealed that Resident #12 had no difficulties with communication, vision, hearing, or cognitive function. Resident #12 received a score of 15/15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Resident #12 reported to the surveyor that it was very important for him/her to: Choose what to wear, take care of their personal belongings, and have family involved in their care. Review of Resident's #12 comprehensive care plan addressed, ADLs Self Care Performance Deficit with the goal to maintain a sense of dignity by being clean, dry odor free and well groomed. Bed mobility, but did not specify their choice for their time to get out of bed. Review of the progress notes from social services dated 4/19/24 revealed that she attempted to call the Social Worker (SW) at the prior facility regarding Resident #12's belongings, but was unsuccessful. No other attempts were documented in the EMR. On 6/17/24 at 9:30 AM, the surveyor met with the Director of Social Services, to inquire regarding Resident #12's personal belongings. The SW informed the surveyor that she called the prior facility several times and could not reach the SW. While in her office she called the facility, and she was prompted to leave a message or to call later. The surveyor then asked the SW what other methods could have been used to communicate with the facility, the SW stated that she could have sent a letter to the facility but had not done so. On 06/18/24 the surveyor met again with the SW and inquired regarding if she was able to contact the prior facility, she stated no. The surveyor then inquired if she discussed the concerns with the facility's Administrator for further guidance she replied, No. On 06/18/24 at 10:30 AM, the surveyor observed the resident sitting at the nursing station, dressed in a hospital gown and was seated in a recliner chair. The resident stated, [he/she] would feel much better, wearing their own personal clothing. On 6/19/24 at 12:30 the survey team presented the above concerns to the facility and requested any documentation regarding how Resident #12's concerns were addressed by the facility. On 6/19/24 at 2:30 PM the Administrator provided a letter dated 6/19/24 that will be forwarded to the facility on behalf of Resident #12. Resident #12 had been at the facility since February. The surveyor contacted the facility on 6/19/24 and left a message with the receptionist for the Director of Nursing and the SW. The facility's SW returned the call and informed the surveyor that she never received any correspondence from the SW. The SW further stated that she was informed only on 6/18/24 that Resident #12 was trying to locate their personal belongings. The SW went on to state that Resident #12's family could not be contacted. A review of the Resident's rights policy dated, last revised. NJAC 8:39-27.1(a)

Based on observation, interview and document review it was determined that the facility failed to ensure the smoking policy was followed to ensure the safety for residents who smoked and held their own cigarettes and lighters. This deficient practice occurred for 2 of 2 residents who held their own lighters (Resident #22 and #25) and was evidenced by the following: a. During the initial tour on 6/13/2024 at 09:49 AM, the surveyor observed Resident #22 in their room. Upon inquiry, Resident #22 informed the surveyor that he/she was a smoker. On 06/17/2024 at 10:38 AM, the surveyor observed Resident #22 in the designated smoking area and was smoking. On 06/18/2024 at 09:00 AM, the surveyor observed Resident #22 in their room. Resident #22 informed the surveyor that they held their own cigarettes and lighter. The resident showed to the surveyor their cigarettes and lighter and stated that the facility was aware. On 6/18/24 at 10:30 AM, the surveyor reviewed Resident #22's medical record. The Admission Summary reflected that Resident #22 was admitted to the facility with diagnoses which included but were not limited to; Respiratory failure (a condition that makes it difficult to breathe on your own), gastro-esophageal reflux disease (a digestive disease in which stomach acid irritates the food pipe lining), and Alcohol Abuse, uncomplicated. A review of the Annual Minimum Data Set (MDS) dated [DATE], an assessment tool used to facilitate resident care, revealed that Resident b#22 had intact cognition. Resident #22 scored 15/15 on the Brief Interview for Mental Status (BIMS). A review of a Care Plan with an initiated date of 06/13/24, revealed a focus area for Smoking. The goal was for Resident #22 will abide by the facility's smoking policy and remain safe during smoking times through the next review. The interventions included to remind residents and their family that all cigarettes, lighters, matches, and smoking paraphernalia must be kept at the nurses station. On 6/18/24 at 9:14 AM, the surveyor interviewed the Smoking Aide who informed the surveyor that alert residents could hold their own cigarettes and lighters. On 06/18/2024 at 11:33 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated, We don't allow residents to have their own lighters for safety reasons. On 06/18/24 at 12:37 PM, the surveyor interviewed the Social worker (SW) who stated, if residents were care planed as an independent smoker, they could hold their own cigarettes and lighter. The surveyor reviewed with the SW Resident #22's care plan. The SW stated then, No, they should not have their lighter. On 06/18/2024 at 12:41 PM, during an interview with the surveyor, on the Licensed Practical Nurse (LPN) Unit Manager confirmed that residents should not hold their lighters because it was a smoking hazard. A review of an undated smoking policy provided by the facility policy titled Smoking Policy revealed under subsection procedure that 8. The smoking monitor will be assigned to observe the courtyard to monitor all smokers. All residents will have their products lit by the smoking monitor or designated staff. 31654 b. On 06/14/24 at 11:50 AM, five surveyors were in the conference room and observed Resident #25 walk past the back of the building by the Sub Acute area bordering the woods, was on a path and was observed smoking a cigarette. At that time, the surveyor reviewed the electronic Medical Record (EMR) for Resident #25 which revealed the following Care Plan: Focus Smoking: Resident is a smoker and is at risk for injury. Resident is an independent smoker and does not require direct supervision to smoke. Date Initiated: 05/27/2024 Revision on: 05/27/2024 Goal: -Resident will abide by facility's smoking policy and remain safe during smoking times through the next review. Date Initiated: 05/27/2024 Revision on: 06/13/2024 Target Date: 10/15/2024 - Resident will smoke in designated areas without occurrence of injury through the next review. Date Initiated: 05/27/2024 Revision on: 06/13/2024 Target Date: 10/15/2024 Interventions - Perform smoking assessment according to facility policy. Date Initiated: 05/27/2024 - Educate resident on smoking policy. Date Initiated: 05/27/2024 - INDEPENDENT SMOKER: Resident is an independent smoker and does not require the use of a smoking apron or direct staff supervision during smoking breaks. Date Initiated: 05/27/2024. (The Care Plan did not indicate the resident was able to hold own smoking material and lighter and walk around the building smoking.) Resident #25's most recent smoking assessment, dated 02/12/24 revealed #3 Is resident physically capable of holding a cigarette, matches/lighter, and lighting and extinguishing own cigarette without assistance; yes; 9. Has resident been instructed in facility policy regarding safety of himself/herself or others; yes; 10. Has resident signed the [Facility Name] smoking agreement and smoker release of responsibility form, yes. On 06/14/24 at 11:58 AM, a surveyor observed Resident #25 entering the building from the main entrance. The surveyor inquired as to what the resident did outside and the Resident stated was outside walking the parameter of the building and was smoking. Resident #25 stated he/she smoked a pack of cigarettes a day and stated kept a personal lighter to light his/her own cigarettes. The Smoking Policy, provided on 06/13/24 at 12:00 by the LNHA revealed Safe smoking assessment and smoking rules. Purpose to determine a resident's level of ability to smoke safely. Procedure: 1. Upon admission, the social worker or admitting nurse will determine if the resident is a smoker. 6. Residents are only permitted to smoke in the designated smoking area. 8. The smoking monitor will be assigned to observe the courtyard to monitor all smokers. All residents will have their products lit by the smoking monitor or designated staff member. On 06/18/24 at 11:30 AM, the surveyor conducted an interview with the LNHA, in the presence of the survey team, regarding the smoking policy. The LNHA confirmed the policy was the current policy and asked per the policy could a resident hold their own lighter and light there own cigarettes. The LNHA stated, we don't allow them to have lighters and asked why not and the LNHA stated, safety. NJAC 8:39-31.6 (e)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a resident bathroom toilet (Resident room [ROOM NUMBER]) in a sanitary working condition for four days and was evidenced by the following: On 06/13/2024 at 9:58 AM, during initial tour of the facility, the surveyor observed the toilet in Resident room [ROOM NUMBER]. The toilet bowl was observed with brown debris and paper products in the bowl. There was no water observed in the toilet. The resident stated that the toilet does not work, and the facility was aware the toilet had been broken for a few days. On 06/13/2024 at 12:59 PM, the surveyor reviewed the unit maintenance log sheets. The toilet in Resident room [ROOM NUMBER] was not on the log sheets to be repaired since 5/24/24. There was a work order dated 6/12/2024 for the paper towel dispenser in Resident room [ROOM NUMBER] needing batteries which was completed the same day. On 06/13/2024 at 1:12 PM, the surveyor observed the toilet in Resident room [ROOM NUMBER]. The toilet bowl was observed with brown debris and paper products in the bowl. There was no water observed in the toilet. On 06/17/2024 at 8:08 AM, the surveyor observed the toilet in Resident room [ROOM NUMBER]. The toilet bowl was observed with brown debris and paper products in the bowl. There was no water observed in the toilet. At 8:44 AM, the resident stated that the toilet had not been repaired. During an interview with the surveyor on 06/17/2024 at 8:44 AM, the Certified Nursing Assistant #1 (CNA) stated that when items needed to be repaired, she informed the Unit nurse then completed a work order in the maintenance log located on the unit. The CNA stated that Resident room [ROOM NUMBER]'s toilet was often out of order as the resident flushed paper towels in the toilet bowl. The CNA further stated that she believes the toilet was plunged on 06/10/2024. During an interview with the surveyor on 06/17/2024 at 8:48 AM, the Licensed Practical Nurse #2 (LPN#2) stated that Resident room [ROOM NUMBER] toilet was always messed up because the resident likes to place towels in the toilet. She stated it is usually unclogged every other day. When asked if she reported the clogged toilet recently, she replied, No. She stated that she had not been at the facility since 06/14/2024. On 06/18/2024 at 8:55 AM, the surveyor interviewed the Unit Manager on the CD Unit. The UM confirmed that all equipments needed repair must generate a work order. The order would be placed in the book and the maintenance director would be verbally informed. The UM revealed that the concern with Resident #72's toilet was an ongoing issue. The surveyor then inquired if the toilet should be in disrepair, the UM stated, No. On 06/18/2024 at 9:50 AM, the surveyor interviewed the Maintenance Director (MD) who revealed that all work orders were entered in the maintenance log located on each unit and at times would verbally communicate the concern. The MD stated the toilet in Resident room [ROOM NUMBER] should not be clogged for 4 days. He stated that a toilet being clogged for 4 days was an inconvenience to the resident and unhealthy. A review of the facility policy titled Maintenance Inspection with an implemented date of 11/15/23 reflected that it is the policy of this facility to utilize a maintenance inspection checklist to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. NJAC 8:39-31.4(a)

Based on observation and interview it was determined that the facility failed to maintain all resident rooms and common areas in a clean and sanitary manner. The deficient practice occurred on 1 of 3 units and in the Sub-Acute smoking courtyard and was evidenced by the following: On 6/13/24 at 10:41 AM, two surveyors toured the Sub-Acute smoking courtyard and observed cigarette butts were located throughout the lawn area surrounding the gazebo, on top of a garbage can and partially filling the inside of an open bucket that rested on the ground which included empty cigarette packages. There were signs posted to utilize cigarette disposal not the ground. On 06/17/24 at 9:39 AM, the surveyor observed Resident #47 in bed and observed the privacy curtain was stained in several areas, there was soiled areas on several walls and a broken window blind with flies in the room. The surveyor asked about the flies and the resident confirmed there were flies in the room. On 06/19/24 at 11:13 AM, the surveyor, in the presence of the survey team informed the LNHA, Director of Nursing and Interum Infection Preventionist nurse of the above findings. NJSA 8:39-4.1(11)

Based on interviews, medical record review, and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility was in compliance with the following regulatory requirements, which affected the safety of all residents in the facility. The LNHA failed to a.) oversee the Infection Preventionist (IP) and Assistant Director of Nursing (ADON) to ensure that the facility followed their Outbreak Response Plan, b.) maintain compliance with Regulation F880, and c.) ensure the implementation of Transmission Based Precautions (TBP) in accordance with CDC guidance. This affected 11 unvaccinated residents with a known exposure to COVID-19, which are considered, according to CDC, as PUI (persons under investigation), for 2 of 3 units (A-B and C-D Units). Refer to F880K as it pertains to the facility's failure to ensure the implementation of Infection Control Practices and Precautions during an identified COVID-19 outbreak. During the Standard Survey conducted on 12/30/21, the surveyors identified deficient practices concerning Infection Control related to the identification of residents who had been exposed to staff members with known COVID-19 positive test results; and timely implementation of TBP for these residents. These deficient practices were identified on 2 of 3 nursing units (A-B and C-D Units). This deficient practice was evidenced by the following: A review of the Administrator.s job description provided by the facility revealed the following: Position Summary: This position is responsible to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meet residents' needs in accordance with federal, state and local regulations. Also, develop and maintain systems that are effective and efficient to operate the facility in a financially sound manner. Responsibilities/Accountabilities included: Develop, maintain and implement operational policies and procedure to meet residents' need in compliance with federal, state and local requirements; Develop and enforce a monitoring program to assure compliance with federal, state and local requirements; Prepare reports for, and attend meetings with the governing body regarding the total activities of the nursing home, as well as governmental developments, which effects health care;Establish systems to enforce the facility policies and procedures; Interpret all federal, state and local regulations for the facility staff; Establish systems to ensure compliance with all federal, state and local regulation. On 12/10/21 at 12:27 PM, the facility's LNHA was notified that an Immediate Jeopardy (IJ) situation was identified related to his failure to oversee the Infection Preventionist (IP) and Assistant Director of Nursing (ADON) to ensure that the facility followed their Outbreak Response Plan, maintain compliance with Regulation F880, and ensure the implementation of Transmission Based Precautions (TBP) in accordance with CDC guidance for a period of 12/03/21-12/09/21. On 12/10/21, the facility's removal plan was accepted. The non-compliance remained on 12/10/2021 for actual harm that is not immediate jeopardy based on the following: The gfacility's removal plan included the follwoing: - Review all state and federal guidelines pertaining to Covid-19 - Review facility policies to ensure we are aligned with all mandated regulations - Review the infection preventionist audit tool from the New Jersey Department of Health (NJDOH) that will allow us to provide an environment that protects residents, staff, and visitors from acquiring or transmitting Covid-19 and any other associated infections or communicable diseases. - Review the requirements for Covid-19 testing of staff and residents that are fully vaccinated and non-vaccinated during an outbreak, weekly or bi-weekly testing depending on the county levels, and exposure - Quarantine timeframes and who needs to be quarantined and who does not - Review the Co-horting process - Ensure all contact tracing and risk assessments are being completed - Address environmental controls that includes isolation rooms, plastic barriers, sanitation stations, specialized EPA disinfectants, appropriate infectious disease, and special areas for contaminated waste - Review our emergency operations plan, we will maintain a supply of personal protective equipment (PPE), including moisture-barrier gowns, face masks/goggles, assorted sizes of disposable N95 respirators or higher, surgical masks, approved disinfectants, and gloves to meet to requirements of a 30-day supply. The admissions department will provide the administration with a log on each resident's start and end date on TBP. The administrator will round the unit daily and ensure all necessary PPE supplies are in place. The administrator will conduct competency on each employee on the unit to ensure they are in compliance. Effectively immediately, on 12-10-2021 at 3:45 PM, the Regional Director will be re-educating the LNHA on all areas listed above, meet with the LNHA weekly, and expect him to demonstrate return competency in all areas. All findings will be reviewed during our QAPI meeting. A review of the facility's Outbreak Plan, revised on 09/10/21, indicated that testing would begin immediately upon identifying a single new case of COVID-19 infection in any staff or residents. The policy further instructed to refer to the CDC guidance Interim Infection Prevention and Control Recommendations to prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes. for further information on contact tracing and broad-based testing. Under the Cohort Policy section, the policy indicated that Cohort 2 consisted of both symptomatic and asymptomatic residents who test negative for COVID-19 with an identified exposure to someone who is positive, regardless of vaccination status. The policy further indicated that exposed individuals would be quarantined for 14 days from the last exposure date, regardless of negative test results. During an interview with the surveyors on 12/09/21 at 11:01 AM, the ADON stated that the facility was currently in a COVID-19 outbreak which started 11/30/21. There were no positive residents in the facility, and six staff members tested positive for COVID-19. One positive staff member was a nurse who worked on Thursday, 12/02/21, went on vacation, and then tested positive during vacation. One CNA tested positive before her shift and was sent home, but the ADON did not provide the date at that time. A second CNA worked on the 11 PM-7 AM shift on 11/29/21 and felt sick during the shift with flu-like symptoms. The CNA went home, tested on Wednesday, and called out of work with a positive COVID-19 result on Friday, 12/03/21. The ADON stated that the facility completed two rounds of rapid testing, and no residents exhibited signs/symptoms of COVID-19. As a result, they did not initiate TBP for any exposed residents. At that time, the ADON provided the team with a Resident & Staff Outbreak Line List (Line List) dated 12/09/21. The surveyors reviewed the Line list, which revealed the following: 1. The facility became aware on 12/03/21 that CNA #1, who last worked on 11/29/21, tested positive for COVID-19 on 12/01/21. Once the facility became aware on 12/03/21 that CNA#1 tested positive and was experiencing symptoms following her shift on 11/29/21, the facility did not identify possible exposed residents and did not implement TBP. 2. The facility became aware on 12/04/21 that LPN #1 tested positive for COVID-19. Once the facility became aware on 12/04/21 that LPN #1 tested positive, the facility did not identify possible exposed residents and did not implement TBP. 3. The facility became aware on 12/07/21 that CNA #2 tested positive for COVID-19. Once the facility became aware on 12/07/21 that CNA#2 tested positive, the facility did not identify possible exposed residents and did not implement TBP. 4. The facility became aware on 12/08/21 that CNA #3 tested positive for COVID-19. Once the facility became aware on 12/08/21 that CNA #3 tested positive, the facility did not identify possible exposed residents and did not implement TBP. During an interview with the survey team on 12/09/2021 at 12:35 PM, the Infection Preventionist (IP) confirmed that the identified residents on CNA #1's assignment were not vaccinated for COVID-19. The IP further stated that the process for contact tracing of a positive employee included looking back 48 hours prior to the positive test to identify residents and staff who had contact with the positive employee for greater than 15 minutes. The IP then stated that all residents and staff, regardless of vaccination status, undergo two rounds of testing for COVID-19. During the same interview with the survey team, the ADON stated that on Friday, 12/03/21, CNA #1 notified the facility that she became symptomatic after her 11 PM - 7 AM shift on Monday, 11/29/21, took a COVID-19 test on Wednesday, 12/01/21, and received a positive COVID-19 test result on Friday, 12/03/21. The ADON further stated that residents who are unvaccinated and identified as exposed to someone with COVID-19 were monitored for signs and symptoms of COVID-19 and that staff performed hand hygiene and wore surgical masks when caring for those residents. The ADON also stated that TBP were not implemented for the unvaccinated, exposed residents. During the same interview with the survey team, the IP explained that new admission and re-admission residents are placed on PUI isolation for 14 days due to their unknown exposure status to COVID-19. The IP further stated the importance of placing residents on Persons Under Investigation (PUI) isolation is because you can still test positive and shed the virus within 14 days of exposure. During an interview with the survey team on 12/09/2021 at 2:29 PM, the IP confirmed that the identified residents on CNA #2 and CNA #3's assignments were not fully vaccinated for COVID-19 During an interview with the surveyor on 12/10/21 at 12:27 PM, the LNHA stated that he thought this tag would be included in the F880. The LNHA did not comment on his job responsibilities related to this deficient practice. During an interview with the survey team on 12/16/2021 at 11:45 AM, the IP stated that residents who have been exposed to COVID-19, regardless of vaccination status, are placed on PUI isolation for 14 days and that the required Personal Protective Equipment (PPE) for those rooms included an N95 mask, eye protection, a gown, and gloves. The IP further stated that when an employee tests positive for COVID-19, contact tracing is performed to identify residents who had contact with the employee up to 48 hours prior to the positive test result so that non-vaccinated, exposed residents can be placed on PUI isolation. The IP added that it is important to wear the correct PPE to protect the residents and staff from COVID-19. Review of the CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated 09/10/2021, included unvaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection, should be placed in quarantine for 14 days after their exposure, even if [CONDITION(S)] testing is negative. Healthcare Professionals (HCP) caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). If testing of close contacts reveals additional HCP or residents with [CONDITION(S)]-CoV-2 infection, contact tracing should be continued to identify residents with close contact to the newly identified individual(s) with [CONDITION(S)]-CoV-2 infection. The guidelines further included that unvaccinated residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. The resident should not participate in group activities. NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to appropriately identify residents exposed to COVID-19 as Persons Under Investigation (PUI) for the COVID-19 virus; and as a result, failed to implement Transmission Based Precautions (TBP) in a timely manner to prevent the transmission of COVID-19. This deficient practice was identified for 11 of 11 residents (Residents #10, #11, #25, #48, #51, #60, #63, #65, #73, #84, and #94) who were exposed to four known COVID-19 positive staff members on 2 of 3 nursing units (A-B Unit and C-D Unit) during a Standard Survey on 12/09/21. The facility's failure to identify residents exposed to COVID-19 positive staff and implement strategies to prevent the spread of COVID-19 posed a serious and immediate threat to the safety and wellbeing of all non-ill residents (residents who were negative for COVID-19). This resulted in an Immediate Jeopardy (IJ) situation that began on 12/03/21 when the facility was notified of the confirmed COVID-19 positive CNA #1. The facility Administration was notified of the IJ on 12/09/21 at 6:22 PM. The immediacy was removed on 12/10/2021, based on an acceptable Removal Plan that was implemented by the facility and verified by the surveyors during the Standard Survey conducted on 12/10/2021. The non-compliance remained on 12/10/2021 for actual harm that is not immediate jeopardy based on the following: The evidence was as follows: During an interview with the surveyor on 12/09/21 at 8:30 AM, the Assistant Director of Nursing (ADON) stated there were no COVID-19 positive cases in the facility. The ADON further stated there were three units, A-B, C-D, and G-H, and the required Personal Protective Equipment (PPE) for the A-B and C-D Units was a surgical mask. The G-H Unit included long-term care residents, new admissions, and readmissions. The ADON stated that two residents on the G-H Unit were recently admitted and considered PUI. The required PPE in the hallways of the G-H Unit were surgical masks, and staff dons an N95 mask, gown, gloves, and eye protection prior to entering a PUI room. During a follow-up interview with the ADON on 12/09/21 at 11:01 AM, the ADON stated that the facility was currently in a COVID-19 outbreak which started 11/30/21. There were no positive residents in the facility, and six staff members tested positive for COVID-19. One positive staff member was a nurse who worked on Thursday, 12/02/21, went on vacation, and then tested positive during vacation. One CNA tested positive before her shift and was sent home, but the ADON did not provide the date at that time. A second CNA worked on the 11 PM-7 AM shift on 11/29/21 and felt sick during the shift with flu-like symptoms. The CNA went home, tested on Wednesday, and called out of work with a positive COVID-19 result on Friday, 12/03/21. The ADON stated that the facility completed two rounds of rapid testing, and no residents exhibited signs/symptoms of COVID-19. As a result, the facility did not initiate TBP for any exposed residents. At that time, the ADON provided the team with a Resident & Staff Outbreak Line List (Line List) dated 12/09/21. The surveyors reviewed the Line list, which revealed the following: 1. The facility became aware on 12/03/21 that a Certified Nursing Assistant #1 (CNA), who last worked on 11/29/21, tested positive for COVID-19 on 12/01/21. Once the facility became aware on 12/03/21 that CNA #1 tested positive and was experiencing symptoms following her shift on 11/29/21, the facility did not identify possible exposed residents and did not implement TBP. 2. The facility became aware on 12/04/21 that a Licensed Practical Nurse #1 (LPN) tested positive for COVID-19. Once the facility became aware on 12/04/21 that LPN #1 tested positive, the facility did not identify possible exposed residents and did not implement TBP. 3. The facility became aware on 12/07/21 that CNA #2 tested positive for COVID-19. Once the facility became aware on 12/07/21 that CNA #2 tested positive, the facility did not identify possible exposed residents and did not implement TBP. 4. The facility became aware on 12/08/21 that CNA #3 tested positive for COVID-19. Once the facility became aware on 12/08/21 that CNA #3 tested positive, the facility did not identify possible exposed residents and did not implement TBP. The surveyors reviewed the Line List, COVID-19 Contact Tracing Forms (Contact Tracing Form), staff assignments, and vaccination status of the staff and residents provided by the facility. 1. CNA #1: Review of the staff vaccination status revealed that CNA #1 was fully vaccinated. Review of the Line List indicated that the facility became aware on 12/03/21 that a CNA #1 tested positive for COVID-19 on 12/01/21. The Line List reflected, Saff [Staff] called in facility on 12/3/21 stated that started to feel sick on 11/29 after her shift. Went to get tested at RidAid [Rite Aid] on 12/1/21 PCR [Polymerase Chain Reaction] test result resived [received] positive on 12/3/21. Called the facility to notify of results. Last day of work 11/29/21. Quratined [quarantined] for 14 days at home. Fully vaccinated. Once the facility became aware on 12/03/21 that CNA #1 tested positive and was experiencing symptoms following her shift on 11/29/21, the facility completed a Contact Tracing Form dated 12/03/21, which reflected that CNA #1 Came into contact with the following for longer than a combined total of 15 minutes throughout the shift at closer than 6 feet in the last 24 hours: Assignment #3. [indecipherable]. The Contact Tracing Form further revealed Testing Dates and Results: 12/1/21 PCR test at Rite Aid results received on 12/3/21 + [positive] with an Outcome: Quarantine at home. At that time, the facility did not identify possible exposed residents on CNA #1's assignment and implement TBP. The surveyors reviewed CNA #1's 11 PM - 7 AM assignments on the C-D Unit and identified that on 11/27/21-11/28/21, CNA #1 was assigned to provide care for 15 residents, two of which were unvaccinated (Residents #51 and #84). The 11/28/21-11/29/21 assignment reflected that CNA #1 was assigned to provide care for nine residents, two of which were unvaccinated (Residents #10 and #51). On 12/10/21 at 8:30 AM, the ADON provided a revised Contact Tracing Form dated 12/03/21, which revealed that on 11/28/21, CNA #1 was in contact with two unvaccinated residents [Residents #10 and #51], and 2 half vaccinated residents [#47 and #102]. The Contact Tracing form further reflected an Outcome: quarantine at home x 14 days. Residents in contact placed on TBP x 14 days. The surveyors reviewed CNA #1's 11 PM - 7 AM assignment on the C-D Unit dated 11/27/21-11/28/21 and confirmed that CNA #1 was assigned to provide care for Residents #47, #51, #84, and #102. The surveyors further reviewed CNA #1's 11 PM - 7 AM assignment on the C-D Unit dated 11/28/21-11/29/21 and confirmed that CNA #1 was assigned to provide care for Residents #10 and #51. 2. LPN #1's staff vaccination status review revealed that LPN #1 was unvaccinated. Review of the Line List indicated that the facility became aware on 12/04/21 that LPN #1 tested positive for COVID-19. The Line List reflected, Employee last day worked on 12/2 and went on vacation. Anticipated to return to work on 12/7. Called facility stated that she started to feel sick, sore throat rapid tested Positive on 12/4 while been on vacation. Employee staying home quarantine. Once the facility became aware that LPN #1 tested positive, the facility completed a Contact Tracing Form dated 12/07/21, which reflected that LPN #1 Came into contact with the following for longer than a combined total of 15 minutes throughout the shift at closer than 6 feet in the last 24 hours: No contact with residents. The Contact Tracing Form further revealed Testing Dates and Results: employee rapid test on 12/4/21 on vacation. Vacation days 12/3/21 - 12/6/21 with an Outcome: quarantine at home x 14 days. Notified job of possible rapid test. Did not return to work. At that time, the facility did not identify possible exposed residents on LPN #1's assignment and implement TBP. The surveyors reviewed LPN #1's 7 AM - 3 PM and 3 PM - 11 PM assignments on the A-B Unit. They identified that on 12/02/21, LPN #1 was assigned to provide care for 22 residents, three of which were unvaccinated (Residents #11, #60, and #94) and one partially vaccinated resident receiving one (1) dose of a two-dose series (Resident #63). On 12/10/21 at 8:30 AM, the ADON provided further information that Resident #11 was fully vaccinated. On 12/10/21 at 8:30 AM, the ADON provided a revised Contact Tracing Form dated 12/07/21, which revealed that on 12/02/21, LPN #1 also had contact on 12/2/21 with two unvaccinated residents [Residents #60 and #94]. One half vaccinated resident [Resident #63]. The revised Contact Tracing Form further reflected that Resident half vaccinated and unvaccinated placed on PUI + [and] TBP x14 days. The surveyors reviewed LPN #1's 7 AM - 3 PM and 3 PM - 11 PM assignments on the A-B Unit dated 12/02/21 and confirmed that LPN#1 was assigned to provide care for Residents #60, #63, and #94. 3. Review of CNA #2's staff vaccination status revealed that CNA #2 was unvaccinated. Review of the Line List indicated that the facility became aware on 12/07/21 that a CNA #2 tested positive for COVID-19. The Line List reflected, Employee was rapid test before her shift on 12/7 positive COVID-19. Send home imidiatly [immediately], no s/s [signs/symptoms] reported by employee, no direct contact was made with residents. Last day at work 12/5. Once the facility became aware on 12/07/21 that CNA #2 tested positive, the facility completed a Contact Tracing Form dated 12/07/21, which reflected that CNA #2 Came into contact with the following for longer than a combined total of 15 minutes throughout the shift at closer than 6 feet in the last 24 hours: Non [none] sent home before providing care to Residents. The Contact Tracing Form further revealed Testing Dates and Results: Rapid test 12/7/21 with an Outcome: sent home to quarantine x 14 days. At that time, the facility did not identify possible exposed residents on CNA #2's assignment and implement TBP. The surveyors reviewed CNA #2's 3 PM - 11 PM assignment on the C-D Unit. They noted that on 12/05/21, CNA #2 was assigned to provide care for 14 residents, two of which were unvaccinated (Residents #25 and #73) and one partially vaccinated resident receiving one (1) dose of a two-dose series (Resident #65). On 12/10/21 at 8:30 AM, the ADON provided a revised Contact Tracing Form dated 12/07/21 for CNA #2, which revealed that on 12/5/21, Employee was in contact with the following Residents on 12/5/21: [Residents #25 and #73] unvaccinated and 1 [one] half vaccinate [vaccinated] [Resident #65]. The contact Tracing Form further reflected that Residents in contact with employee placed on TBP x14 days. The surveyors reviewed CNA #2's 3 PM - 11 PM assignment on the C-D Unit dated 12/05/21 and confirmed that CNA #2 was assigned to provide care for Residents #25, #65, and #73. 4. Review of CNA #3's staff vaccination status revealed that CNA #3 was unvaccinated. Review of the Line List indicated that the facility became aware on 12/08/21 that a CNA #3 tested positive for COVID-19. The Line List reflected, Emplyee [Employee] rapid tested Positive before the sift [shift] on 12/8. Rapid test is positive. Sent home imiditaly [immediately] to quarantine. Last day off work before testing on 12/6. Once the facility became aware on 12/08/21 that CNA #3 tested positive, the facility completed a Contact Tracing Form dated 12/08/21, which reflected that CNA #3 Came into contact with the following for longer than a combined total of 15 minutes throughout the shift at closer than 6 feet in the last 24 hours: N/A [not applicable]. The Contact Tracing form further revealed Testing Dates and Results: 12/8/21 rapid test + [positive] with an Outcome: employee sent home immediately, quarantine x 14 days. At that time, the facility did not identify possible exposed residents on CNA #3's assignment and implement TBP. The surveyors reviewed CNA #3's 7 AM - 3 PM assignment on the C-D Unit and noted that on 12/06/21, CNA #3 was assigned to provide care for nine residents, one of which was unvaccinated (Resident #48). On 12/10/21 at 8:30 AM, the ADON provided a revised Contact Tracing Form dated 12/08/21, which revealed that on 12/6/21, CNA #3 Employee was in contact with unvaccinated Resident on 12/6/21 [Resident #48]. The Contact Tracing Form further reflected that Resident in contact with + [positive] employee placed on TBP x14 days. During an interview with the survey team on 12/09/2021 at 12:35 PM, the Infection Preventionist (IP) confirmed that the identified residents on CNA #1's assignment were not vaccinated for COVID-19. The IP further stated that the process for contact tracing of a positive employee included looking back 48 hours prior to the positive test to identify residents and staff who had contact with the positive employee for greater than 15 minutes. The IP then stated that all residents and staff, regardless of vaccination status, undergo two rounds of testing for COVID-19. During the same interview with the survey team, the ADON stated that on Friday, 12/03/21, CNA #1 notified the facility that she became symptomatic after her 11 PM - 7 AM shift on Monday, 11/29/21, took a COVID-19 test on Wednesday, 12/01/21, and received a positive COVID-19 test result on Friday, 12/03/21. The ADON further stated that residents who are unvaccinated and identified as exposed to someone with COVID-19 are monitored for signs and symptoms of COVID-19 and that staff perform hand hygiene and wear surgical masks when caring for those residents. The ADON also stated that TBP were not implemented for the unvaccinated, exposed residents. During the same interview with the survey team, the IP explained that new admission and readmission residents are placed on PUI isolation for 14 days due to their unknown exposure status to COVID-19. The IP further stated the importance of placing residents on PUI isolation is because you can still test positive and shed the virus within 14 days of exposure. During an interview with the survey team on 12/09/2021 at 2:29 PM, the IP confirmed that the identified residents on CNA #2's and CNA #3's assignments were not fully vaccinated for COVID-19 During an interview with the survey team on 12/16/2021 at 11:45 AM, the IP stated that residents who have been exposed to COVID-19, regardless of vaccination status, are placed on PUI isolation for 14 days and that the required Personal Protective Equipment (PPE) for those rooms included an N95 mask, eye protection, a gown, and gloves. The IP further stated that when an employee tests positive for COVID-19, contact tracing is performed to identify residents who had contact with the employee up to 48 hours prior to the positive test result so that non-vaccinated, exposed residents can be placed on PUI isolation. The IP added that it is important to wear the correct PPE to protect the residents and staff from COVID-19. A review of the facility's Outbreak Plan, revised 09/10/21, included the following: Testing of staff and Residents during an Outbreak investigation: A. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have an option to perform outbreak testing through two approaches, contact tracing or broad based (e.g., facility wide) testing. For further information on contact tracing and broad-based testing, see CDC guidance Interim Infection Prevention and Control Recommendations to prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes. Cohort Policy: 1. Cohort 1- COVID-19 Positive. This cohort consists of both symptomatic and asymptomatic patients/residents who tested positive for COVID-19, regardless of c\vaccination status. 2. Cohort 2- COVID-19 Negative; Exposed. This cohort consists of symptomatic and asymptomatic patients/residents who test negative for COVID-19 with an identified exposure (i.e., close contact) to someone who is positive, regardless of vaccination status. Exposed individuals should be quarantined 14 days from last exposure, regardless of negative test results. 3. Cohort 3- COVID-19 Negative/ Not exposed. This cohort consists of patients/residents who test negative for COVID-19 with no COVID-19 like symptoms and are thought to have no know exposures. 4. Cohort 4-New admissions or Readmissions Observation: This cohort consists of all new and readmitted patients/residents from the community or other healthcare facilities who are not fully vaccinated. Review of the CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated 09/10/2021, included unvaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure, even if [CONDITION(S)] testing is negative. Healthcare Professionals (HCP) caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator. If testing of close contacts reveals additional HCP or residents with [CONDITION(S)]-CoV-2 infection, contact tracing should be continued to identify residents with close contact to the newly identified individual(s) with [CONDITION(S)]-CoV-2 infection. The guidelines further included that unvaccinated residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. They should not participate in group activities. NJAC 8:39-27.1 (a) F880 continues at a lower s/s based on the following: Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) implement personal protective equipment according to the New Jersey Department of Health (NJ DOH) and Centers for Disease Control and Prevention (CDC) guidelines to minimize the potential spread of infection to residents on 3 of 3 units (A-B Unit, C-D Unit, and G-H Unit) and b.) minimize the potential spread of infection to residents for 1 of 3 nurses observed during medication pass on 1 of 3 units (C-D Unit). This deficient practice was evidenced by the following: 1. Upon entrance into the facility on [DATE], the ADON stated that the required PPE for the PUI rooms were full PPE, which consisted of an N95 mask (respirator), eye protection, gown, and gloves, and the required PPE for non-PUI rooms was a surgical mask. The ADON further stated that eye protection was not required in non-PUI rooms. On 12/13/21, from 8:33 AM to 9:10 AM, Surveyor #2 observed the LPN #2, on the C-D Unit, prepare and administer medications to two residents (Resident #76 and Resident #13) without donning eye protection. On 12/13/21, from 8:50 AM to 9:22 AM, Surveyor #1 observed LPN #7 on the A-B Unit, prepare and administer medications to three residents (Resident #5, Resident #30, and Resident #56) without donning eye protection. On 12/13/21 at 9:55 AM, Surveyor #3 observed a staff member talking with a resident while on the G-H unit. The staff member's PPE consisted of an N95 mask without eye protection. On 12/13/21 at 9:55 AM, Surveyor #4 observed a CNA in the hallway of the A-B unit, within 6 feet of a resident, wearing only a surgical mask with no eye protection. Surveyor #4 also observed a housekeeper sweeping the floor around the nurses' station and hallway near room numbers 15-23, wearing only a surgical mask without eye protection. On 12/13/21 at 9:57 AM, Surveyor #4 observed a CNA enter a resident's room wearing only a surgical face mask, without eye protection. On 12/13/21 at 10:00 AM, Surveyor #4 observed two therapists, one wearing only a surgical mask and the other wearing an N-95 mask, both without eye protection, performing direct care with the resident. One therapist applied a surgical mask on the resident while the other therapist assisted the resident by putting their shoes on their feet. At 10:06 AM, the surveyor then observed the same two therapists using handheld assistance, ambulating the resident with a walker in the hallway. On 12/13/2021 at 12:40 PM, Surveyor #5 observed the Social Worker (SW) enter a PUI room on the G-H unit wearing a surgical mask under her N95 mask, a gown, and gloves. The SW did not don eye protection prior to entering the PUI room. During an interview with Surveyor #5 on 12/13/2021 at 12:43 PM, the Social Worker (SW) stated that the resident in the PUI room was in isolation for being exposed to a COVID-19 positive person. The SW further stated that the required PPE for the PUI room consisted of an N95 mask, a gown, and gloves. When asked if eye protection was required in the PUI room, the SW responded, I don't believe so. The SW further stated that she was unsure of the correct order of donning the surgical mask and N95 mask and that she wore the surgical mask underneath the N95 for comfort. The SW then stated that the importance of wearing the correct PPE in the PUI room was to protect herself and the resident from spreading or contracting COVID-19. On 12/14/21, from 8:55 AM to 9:02 AM, Surveyor #1 observed LPN #3 on the C-D Unit prepare and administer medications to one resident (Resident #88) without donning eye protection. On 12/14/21 from 9:13 AM and 9:35 AM, Surveyor #1 observed LPN #3 and LPN#4 complete the sacral wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/14/21 at 09:19 AM, Surveyor #4 observed all staff members on the A-B unit wearing only surgical face masks without eye protection. On 12/14/21 at 9:25 AM, Surveyor #3 observed LPN #6 pushing a medication cart down the hall on the G-H unit. LPN #6's PPE consisted of an N95 mask with no eye protection. During an interview with Surveyor #3 on 12/14/2021 at 9:28 AM, LPN #6 stated the required PPE on the G-H unit was an N95 mask. LPN #6 further stated that she would don the required PPE when entering a PUI room. LPN #6 added the required PPE for the PUI room consisted of an N95 mask, a gown, and gloves. When asked if eye protection was required on the G-H unit, LPN #6 stated that staff donned eye protection prior to entering the PUI room. LPN #6 further stated that eye protection was not required while on the G-H unit. During an interview with Surveyor #1 on 12/16/21 at 9:33 AM, LPN #5 stated that she currently worked as an agency nurse at the facility and previously worked full time at the facility, on and off for nine years. LPN #5 stated that no residents on the A-B Unit had symptoms, were exposed to, or had an active case of COVID-19. The required PPE for the A-B Unit was a surgical mask, and the staff do not have to wear eye protection. The agency provided PPE education. During an interview with Surveyor #2 on 12/16/21 at 9:42 AM, CNA #4 on the C-D Unit responded to the surveyor's question about the type of PPE that should be worn while care is rendered to residents. CNA #4 stated it is necessary to wear a gown, gloves, face mask, and goggles when there is a sign on the door and a storage container next to the room. The sign usually indicates to see the nurse because there are transmission-based precautions. In such cases, CNA #4 indicated all the previously mentioned articles of PPE should be worn, in addition to an N-95 face mask. If there is no sign and no transmission-based precautions in place, CNA #4 stated it was necessary to always wear a face mask, knock on the door to enter the room and wear the face mask and a pair of gloves while rendering care to residents. CNA #4 further stated PPE training was most recently conducted with staff last month by an individual who was no longer employed at the facility. During an interview with Surveyor #2 on 12/16/21 at 9:50 AM, LPN #4 on the same Unit addressed the surveyor's question regarding the type of PPE that should be worn while care is rendered to residents. LPN #4 advised the surveyor that it was always necessary to wear gloves, a mask and perform hand hygiene to render care. LPN #4 stated that staff did not don or doff PPE on this Unit, specifically mentioning that no gowns or booties (shoe coverings) were used on the C-D Unit. In cases where staff is irrigating a wound, they would be expected to wear a face shield or goggles. LPN #4 further clarified that the type of mask to be worn on the Unit should be a surgical mask. PPE training was most recently conducted with staff during the past week or so by the Regional Nurse/Infection Preventionist. During an interview with Surveyor #5 on 12/16/21 at 9:52 AM, CNA #5 for the G-H Unit stated that residents on the Unit were under quarantine isolation and that the required PPE consisted of an N95 mask with a surgical mask over it, eye protection, a gown, and gloves. CNA #5 further stated that PPE is donned prior to entering the isolation room and removed prior to exiting the room. During a follow-up interview with Surveyor #5 on 12/16/2021 at 9:56 AM, LPN #6 stated the residents on the Unit were on PUI isolation and that the required PPE consisted of an N95 mask, surgical mask, eye protection, a gown, and gloves. LPN #6 further stated that PPE is donned prior to entering the PUI room and removed prior to exiting the room. LPN #6 added that the importance of wearing the correct PPE was for infection control. During an interview with Surveyor #4 on 12/16/21 at 10:26 AM, CNA #6 stated she was the CNA for the A-B Unit and only needed to wear a surgical face mask without eye protection on this Unit. CNA #6 further stated that the Unit did not have any COVID-19 positive residents on the Unit. If a resident has a sign on the door indicating isolation, staff was educated to wear a gown, gloves, mask, and face shield prior to entering the isolation room. During an interview with Surveyor #4 on 12/16/21 at 10:29 AM, the housekeeper stated she was responsible for cleaning rooms on the A-B unit. The housekeeper further stated that the PPE required on this Unit was only a surgical face mask, without eye protection. If a resident was positive for COVID-19 or PUI, she would need to wear full PPE, which included a mask, gloves, gown, and face shield prior to entering the resident's rooms. During an interview with Surveyor #1 on 12/16/21 at 10:39 AM, CNA #7 stated that she worked at the facility for four years and was a permanent CNA on the A-B Unit. CNA #7 further stated that the required PPE on this Unit was a surgical mask and gloves when giving care and reviewed daily PPE education. During an interview with Surveyor #5, in the presence of the survey team, on 12/16/2021 at 11:45 AM, the IP stated that the required PPE for the PUI rooms consisted of an N95 mask, eye protection, a gown, and gloves. The IP further stated that staff should don their N95 masks and then a surgical mask over them, so that staff can discard the surgical mask between rooms. When asked about the current NJ DOH COVID-19 Activity Level Index ([NAME]) Score and the CDC COVID Data Tracker County Transmission Rate, the IP was unsure of the [NAME] Score but stated the County Transmission Rate was high or substantial. The IP then noted that the facility utilized PPE according to the regulations to determine what PPE was required throughout the facility. The IP added that it is important to wear the correct PPE to protect the residents and staff from COVID-19. On 12/16/2021 at 12:45 PM, the IP followed up with Surveyor #5 and the survey team to provide the [NAME] Score for the Southeast region of NJ (where the facility is located), which indicated the current activity level was high. The IP also provided the CDC COVID Data Tracker for [NAME] county (where the facility is located), which indicated the transmission rate was high. Review of the NJDOH Executive Directive 20-026 included, Facilities shall implement universal eye protection, in addition to source control and other infection prevention and control measures, for all staff and for compassionate care or essential caregiver visitors unable to maintain social distancing when the NJDOH [NAME] Level is Very High/High or Moderate. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic guidelines, dated 09/10/2021, included, If [CONDITION(S)]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP [healthcare professionals] working in facilities located in counties with substantial or high transmission should also use PPE as described below: . Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. Review of the CDC's How to Properly Put on and Take off a Disposable Respirator guideline included, Do not allow facial hair, hair, jewelry, glasses, clothing, or anything else to prevent proper placement or come between your face and the respirator. 2. On 12/13/21 at 8:58 AM, Surveyor #2 observed LPN #2, upon completion of administering medications to a resident, enter the bathroom of a second resident. There were no paper towels present in the wall dispenser, so the LPN asked a staff member to replace a large roll of paper towels within the dispenser. The LPN then wet her hands, briefly lathered them with soap, and placed both hands under the stream of water while applying friction to her hands. The entire process lasted 12 seconds. Afterward, the LPN prepared medications and administered them to the second resident. During an interview with Surveyor #2 on 12/13/21 at 10:00 AM, LPN #2 described the handwashing process. The LPN explained it was necessary to turn the water on for warmth, use soap, and rub hands, including between the fingers. When asked about the length of time-related to handwashing, LPN #2 stated she sings the Happy Birthday song to herself to know how long to wash and added that the process should take longer than two seconds. She further stated that she probably washes her hands for 60 seconds and that the facility policy indicates that handwashing is longer than 30 seconds. During an interview with Surveyor #2 on 12/16/21 at 12:06 PM, the IP described the facility's handwashing procedure to the survey team. She stated that handwashing occurs with soap and water, followed by lathering the hands and scrubbing them for 20 seconds. The hands are held in a downward manner, and scrubbing should include the area under the nails, so the dirt goes down the drain. The lathering process occurs outside the stream of water because otherwise, there is no point. At this time, the surveyor questioned the wording on the facility's policy, which indicated that hands should be lathered under the stream of water. The IP then stated lathering could occur under the stream of water and referenced CDC guidelines, which indicated to lather for 20 seconds. The IP then stated she could not remember whether lathering of the hands should occur outside or under the stream of water but acknowledged that if the entire handwashing process occurred for a total of 12 seconds, such a practice would be considered problematic because the process was not long enough. The IP then stated she would like to investigate matters further and follow up with the survey team. During an interview with Surveyor #2 and the survey team on 12/16/21 at 12:34 PM, the IP stated it is necessary to scrub hands outside the stream of water per CDC guidelines and referenced a poster to that effect. She further stated that the posters are displayed everywhere and that she understood there was a need [TRUNCATED]

COMPLAINT # NJ 5 Based on observations, interviews, review of the Medical Records (MR), and other pertinent facility documentation on 6/8/2020, it was determined that the facility staff failed to ensure a resident was protected from actual abuse, as well as, failed to follow the Facility's Policies titled Resident Abuse Policy and Abuse Prevention Program, to prevent abuse and report abuse after the incident, for 1 of 5 residents sampled, (Resident #2), when on 6/3/2020 as viewed on the Facility's Security Camera, Resident #2 was roughly handled when a staff member forcefully pulled back the resident's wheelchair causing the resident to fall forward out of the chair, subsequently fell to the floor, and sustained an abdominal injury. A second staff member then forcefully grabbed the resident by the upper arm, causing the resident to be held down in the wheelchair while the 1st staff member roughly pushed the resident backwards in the wheelchair returning the resident to their room. The resident was sent to the hospital complaining of chest pain and was admitted on [DATE], with a [DIAGNOSES REDACTED]. This deficient practice placed Resident #2 and all other residents who were at risk for abuse in an Immediate Jeopardy (IJ) situation. The IJ was identified on 6/8/2020 at 6:58 p.m., when the Facility's Regional MDS (Minimum Data Set) Coordinator (RC) and the Regional Nurse Consultant (RNC), were notified of the IJ and were provided the IJ template. The IJ ran from 6/3/2020 through 6/10/2020 at 11:52 a.m., and was lifted when the facility provided an acceptable Removal Plan. This deficient practice was further evidenced by the following: 1. According to the Face Sheet, Resident #2 was admitted to the Facility originally on 12/20/2017, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), an assessment tool dated 3/30/2020, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14/15, indicating Resident #2 was cognitively intact. The MDS also indicated Resident #2 needed only supervision for Activities of Daily Living (ADLs). Review of the Resident Plan of Care (CP) dated 1/24/2020, revealed a Smoking history. The Goals listed included but were not limited to: The resident will continue to smoke safely. The interventions included but were not limited to: Resident may smoke unsupervised. Further review of the CP revealed Resident #2 had a history of [REDACTED]. 2. According to the Face Sheet Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS an assessment tool dated 4/20/2020, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12/15, indicating Resident #4 had moderate cognitive impairment. The MDS also indicated Resident #4 needed only supervision for Activities of Daily Living (ADLs). Review of Resident #4 Interdisciplinary Care Plan with a last review date of 10/16/2018, revealed under Behavior/Mental that the resident was alert and oriented. Review of the Resident Plan of Care (CP), undated, revealed a Problem listed: Prefers the quiet and comfort of his own room. 3. During an interview on 6/8/2020 at 12:21 p.m., Resident #2 reported that on 6/3/2020, during the evening, he/she went to the nursing station and requested to go out for a smoke. The resident stated there was an argument between him/her and the guy at the nursing station (Behavioral Tech#1.) BT#1 kept telling the resident to go back to his/her room. When the resident refused to go to their room, the staff member (BT#1) came behind him/her and pushed the resident from the wheelchair. The resident reported he/she fell forward to the floor and hit his/her stomach. After the fall there was a verbal argument between the resident and the staff member. The resident then reported he/she was pushed a second time and fell again when the staff member pulled his/her arm. The resident reported the following to the nurse, He pushed me and I'm in pain, having chest pain, I need to go to the hospital it hurts. According to the resident, the nurse looked at his/her stomach. I remember the nurse said to the guy, (staff member) Leave the guy alone. The resident reported the nurse sent him/her to the hospital on [DATE] and he/she had lots of test and was given pain medications During the interview on 6/8/2020 at 12:21 p.m. Resident #2 showed this writer his abdomen. Observed was a discoloration to the abdomen approximately 6 by 6 inches to the left upper quadrant (LUQ) and a discoloration below the navel approximately 3 by 3 inches. Resident #2 pointed to the discoloration of the abdomen and stated, this is what he did, referring to the BT#1. During an interview on 6/8/2020 at 12:40 p.m., Resident #4 (Resident #2's room-mate) stated that on 6/3/2020 in the evening, there was some noise outside the room, and he/she witnessed a staff member pushing Resident #2 twice. Resident #4 also stated, I heard him/her yell when he/she fell , and he/she complained of a lot of pain. Resident #4 then stated, he/she heard the nurse say they were going to send Resident #2 to the hospital. Review of the Facility's Nurse's Notes dated 6/3/2020, untimed, the nurse documented the following: Resident #2 complained of general ill health with mild shortness of breath, the staff applied oxygen and vital signs were checked. The doctor was made aware and the nurse received an order to send the resident to the hospital for an evaluation. The documentation was signed by the Regional Nurse Consultant (RNC). Review of the Physician Order Sheet (POS), dated 6/3/2020, untimed, the nurse documented a physician's order (PO) to send Resident #2 to the emergency room (ER) for an evaluation and treatment which was signed by the RNC. According to the Incident Report dated 6/3/2020 at 4:30 a.m., documented under Describe exactly what happened, The Licensed Practical Nurse (LPN #1) documented the following: The resident was in the hallway (after being warned) the Behavior Techs (BTs), were attempting to return the resident to his/her room. Under Type of Injury, Hematoma was checked. On the body diagram the LPN placed a mark to the left upper quadrant area to indicate where the hematoma was on the body. LPN #1 also reported Resident #2's level of consciousness as AAOx3 (alert and oriented times 3) which refers to a patient who is responsive to his or her environment (alert), and knows person, place and time. During an interview on 6/8/2020 at 12:53 p.m., the Regional MDS Coordinator (RC) reported, that she had no knowledge of any allegation of staff to resident abuse in the facility on 6/3/2020. The RC also verified at that time that she was the nurse that wrote the PO on the POS to transfer the resident to the ER, it was a late entry. I told the nurse when someone goes out you need to write the order. I don't remember who I said it to. The RC further stated that she was not sure if the incident was investigated. It would be the responsibility of the nurse on duty, the supervisor, and the Director of Nursing (DON) to complete an investigation of any alleged abuse. During an interview on 6/8/2020 at 1:00 p.m., the Facility's RNC reported, that she had no knowledge of any alleged abuse, staff to resident, in the facility on 6/3/2020. In addition, she stated the facility does not have a night Supervisor, but someone would be designated as the Charge Nurse. of the Facility. In addition, the RNC reported the DON has been out since 5/28/2020. During an interview on 6/8/2020 at 2:52 p.m., the Admission Office Director (AOD) reported that the hospital social worker calls the Facility to let them know when a resident is ready to be discharged and returned back to the facility. During an interview on 6/8/2020 at 2:56 p.m., the Admission Assistant (AA) reported that she spoke to someone at the hospital on [DATE]. The hospital representative stated Resident #2 agreed to return to the facility if the employee who hurt him was no longer employed there. The AA also identified the employee by his name (BT #2) and stated she spoke to the nurse on C unit regarding the resident's return but was unable to identify the nurse by name. During an interview on 6/8/2020 at 3:25 p.m., the Registered Nurse (RN)/Supervisor reported that she was informed by another staff member on 6/4/2020 of the altercation between a resident and a staff member on 6/3/2020. The RN stated, that she was informed that the resident was belligerent and fell out of his wheelchair and was later sent to the hospital with bruises. She also stated that the BTs were involved in the incident. In addition, the RN stated she viewed the incident report and when the resident returned to the facility from the hospital the resident showed her the bruises. The RN was unable to say if anyone reported the incident to Administration and that she did not report it. The RN/Supervisor also verified that she was in-serviced on abuse when she started working at the facility last November. During an interview on 6/8/2020 at 3:42 p.m., BT #2 reported that on 6/3/2020, he heard the nurse arguing with Resident #2, around 3:00 or 4:00 a.m.,he/she wouldn't wear a mask. The nurse then asked him to assist her to wheel the resident back to their room. The resident was being uncooperative when they attempted to take him/her back to their room. I did not put my hands on him at all. When they reached the doorway, the resident stood up and BT #2 reported he grabbed the resident for safety, but the resident did hit the railing with the right side of the body and upper arm. BT #2 also stated, He grabbed the resident's arm when he/she stood up for safety, so the resident did not fall. BT#2 also verified that he was in-serviced on abuse one month prior. Review of the Facility's Security Camera recording on 6/8/2020 at 4:30 p.m., with the RNC, revealed the following: Resident #2 was observed entering the hallway from his/her room at 2:34 a.m., the resident self-propelled the wheelchair (w/c) towards the nursing station, a few seconds later the resident returned to their room. At 2:46 a.m., Resident #2 again propels the wheelchair back down the hall towards the nursing station. Observed on the video, a few seconds later Resident #2 was sitting in the w/c and BT #1 steps behind the w/c and forcefully pulls the w/c back causing the resident to fall forward onto the floor. A few seconds later Resident #2 was observed back in his w/c after the fall, and BT #2 forcefully grabbed the resident's left upper arm pulling him/her by the arm while BT #1 stood in front of the w/c and forcefully pushed the resident backwards towards their room. Once the staff returned the resident to the room two other staff members appear in view of the camera and walk down the hall to the resident's room. The Facility Administration was able to identify all four staff members present during the incident. During an interview on 6/8/2020 at 5:00 p.m., BT #2 identified himself on the Facility's Security Camera as the one who grabbed Resident #2's arm and forcefully pulled the resident to the room. BT #2 stated, I told you I did grab him/her. When asked: Was it with force? BT #2 responded, I guess it was. BT #2 also admitted he took the resident back to their room against his/her will. During an interview on 6/8/2020 at 5:28 p.m., the Facility's RC and RNC agreed that it was inappropriate for the nurse to document after being warned on the incident report because it could be considered verbal abuse. In addition, the RNC reported Peggy's Law should have been implemented after the incident as well as, the nurse should have done a head to toe assessment on the resident, sent all four involved home, then called 911 for allegations of abuse. In addition, the doctor should have been notified and statements should have been obtained from the resident and all witnesses also the Charge Nurse on the shift should have been notified of the incident. Review of the Hospital's History and Physical (H&P) dated 6/3/2020, revealed the following documentation by the Physician, under History of Present Illness, . presents with abdominal pain. Patient stated he/she was angry because he/she wanted to go outside to get some fresh air. He/she was being quarantined due to testing COVID positive 4 days ago. The patient stated The guy wouldn't let him/her leave then pushed him/her while in the wheelchair, and he/she fell on to the ground hitting his abdomen. The resident reported pain to the left upper quadrant (LUQ) where a hematoma/abrasion was noted on the abdomen. The resident also complained of left lower chest pain The H&P further showed under Physical Exam, Abdomen: Soft, tender at the hematoma site. Bruised area on left upper quadrant as well as mid abdominal area. Review of the Hospital Records CAT (Computed Tomography) Scan date 6/3/2020 at 5:51 a.m., revealed the following results: Abdominal Wall: Mild fat stranding of the subcutaneous fat along the left anterior abdominal wall, likely representing mild posttraumatic soft tissue contusion. Under Impression: 2. Mild soft tissue contusion along the left anterior abdominal wall. Review of the Hospital Records Nursing Documentation on 6/4/2020 and 6/5/2020, the nurses documented the following on Resident #2: Pt (patient) yelling out in pain when changed position in bed from side to side. Pt complaining of pain on bruising on abdomen. Pt refused Tylenol LUQ bruise remains tender to palpation. Pt refused Tylenol. Review of the Facility's Nurse's Notes revealed documentation on 6/6/2020 at 5:15 p.m., that Resident #2 returned from the hospital and was readmitted to the Facility. Review of the Police Investigation Report dated 6/10/2020 at 8:20 a.m., the Patrolman (PM), documented he was dispatched to the Facility for an assault on a patient by an employee. The PM spoke to the Facility's RNC who informed him that Resident #2 was assaulted by 2 nursing aids which resulted in the resident having to go to the hospital for injuries. The PM reviewed the video recording of the incident with the RNC and documented the incident. The PM was given the names of the employee's involved however, after speaking with Resident #2 who confirmed his/her injuries with the PM, the resident stated he/she did not want any further police involvement and the resident confirmed he/she was satisfied the Aides were relieved of their employment at the facility. Review of the facility policy titled Abuse Prevention Program, with a review date of 4/20/2020, under Policy Statement, listed the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat resident's symptoms. Review of the Facility's Resident Abuse Policy undated, which was signed by BT#1 on 4/13/2020, BT#2 on 5/5/2020, BT#3 on 4/4/2020, and BT#4 on 4/13/2020, and found in their employee file as in-serviced. The Policy included but was not limited to the following: It is the policy of the facility to take appropriate steps to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect or abuse (verbal, sexual, physical and mental), and misappropriation of resident property (alleged violations) are reported to the Administrator of the Facility. Anyone witnessing or suspecting any type of abuse towards a resident by any individual, including staff, family, . will immediately, report the violation to the supervisor on duty. This form was signed by the four BT's indicating that they had read and understood the resident abuse policy and knew their responsibilities regarding preventing resident abuse and reporting requirements. Resident #2 was roughly handled when a staff member forcefully pulled back the wheelchair causing Resident #2 to fall forward out of the wheelchair, and subsequently fell to the floor, and sustained an abdominal injury. A second staff member then forcefully grabbed the resident by the upper arm causing the resident to be held down in the wheelchair while the other member roughly pushed the resident backwards in the wheelchair returning him/her to their room against their will. The resident was sent to the hospital requiring treatment of [REDACTED]. The resident was admitted to the hospital on [DATE], with a [DIAGNOSES REDACTED]. This deficient practice placed Resident #2 and all other residents who were at risk for abuse in an Immediate Jeopardy (IJ) situation. The IJ was identified on 6/8/2020 at 6:58 p.m., when the Facility's Regional MDS Coordinator (RC), and the Regional Nurse Consultant (RNC), were notified of the IJ and were provided the IJ template. The IJ ran from 6/3/2020, through 6/10/2020 at 11:52 a.m., and was lifted when the facility provided an acceptable Removal Plan. A revisit to verify the Removal Plan occurred on 6/12/2020. NJAC: 8:39-4.1 (a) 5

COMPLAINT #: NJ Based on observation, interviews and record review, it was determined that the facility failed to ensure a safe environment free of potential fire hazards for 1 of 1 sampled residents (Resident #4) and 8 unsampled residents who smoke. On 8/10/16, the surveyor observed Resident #4 extinguish a cigarette into a plastic cup which was on a wooden table. The cup contained 8 cigarette butts and the surveyor observed that some of the cigarettes had burned holes directly through the cup. There was also a second cup on the wooden table with extinguished cigarette butts in it. In addition, the facility failed to follow their own Smoking Policy by not completing quarterly smoking assessments for 22 of 23 residents that had been identified during their admission assessment as someone who smokes. The Immediate Jeopardy (IJ) to resident safety was identified by the surveyor on 8/10/16, at 11:20 a.m., and reported to the Director of Nursing (DON) and the Corporate Clinical Coordinator Nurse (CCCN) at 11:30 a.m. The IJ was lifted the same day, 8/10/16 at 2:50 p.m., when the facility implemented an acceptable plan of correction (POC). This deficient practice is evidenced by the following: 1. A review of the medical record revealed that Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool, dated 6/7/16, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS also revealed that Resident #4 required assistance from staff for turning from side-to-side while in bed, and for transferring from the bed to the chair. During an interview conducted by the surveyor on 8/10/16 at 11:20 a.m., Resident #4 was seated outside in the facility's courtyard smoking a cigarette. Resident #4 had just finished smoking the cigarette when he/she was looking around for a place to extinguish his/her cigarette. The resident found a plastic cup that was sitting on a wooden table directly next to him/her and extinguished the cigarette into the plastic cup. When the surveyor examined the inside of the cup there were 8 extinguished cigarettes inside the cup and it was observed that some of the cigarettes had burned holes directly through the cup. When asked, Resident #4 stated that it was okay for him/her to put the cigarette out in the cup. At the same time there was a second cup observed sitting on the table and it contained approximately 5 extinguished cigarettes. The surveyor observed that there were 2 staff members sitting in chairs underneath the pavilion in the courtyard talking to each other. There were nine residents smoking cigarettes and 4 ashtray containers available for residents to extinguish their cigarettes. When interviewed on 8/10/16 at 11:25 a.m., both staff members stated that they work for the facility as smoking monitors (SMs). SM #1 told the surveyor that Resident #4 should have extinguished his/her cigarette in an ashtray and not inside a plastic cup. SM #1 stated that he was responsible for lighting the resident's cigarettes and making sure that they didn't burn the house down and start a fire. SM #1 also stated that he did not notice Resident #4 extinguishing the cigarettes inside the plastic cup or notice cigarettes inside the plastic cups. SM#1 shrugged his shoulders as he walked away and said that he could not provide any answers as to why there were cigarette butts inside both of the cups. SM #2 stated that he was assigned to the resident seated next to him on a 1:1 and was only responsible for watching that resident. On 8/10/16 at 11:25 am, the surveyor notified the DON and the CCCN, and gave them the plastic cup filled with the cigarettes butts. The surveyor showed them both the second cup that was outside on the table in the courtyard. When interviewed at this time, the DON and the CCCN both stated that the residents were supposed to extinguish their cigarettes in the ashtrays provided in the courtyard. They also stated that the SMs were in the courtyard to ensure that the residents were kept safe while smoking and that the residents used the ashtrays to extinguish their cigarettes. The DON stated that the nurses were responsible for administering the smoking assessments during the resident's admission assessment and quarterly thereafter. The DON stated these assessments were done to ensure that residents were able to safely smoke and extinguish their cigarettes properly. On 8/10/16 at 1:30 p.m., the surveyor reviewed a form titled Resident Smoking assessment dated [DATE] for Resident #4 in the presence of the DON and the CCCN which revealed that the resident was identified during his/her admission assessment as being a smoker. The unsupervised smoking box was the only box checked on the form which indicated that Resident #4 could smoke his/her cigarettes unsupervised. However, an additional review of the form revealed that the nurse did not answer and/or complete any of the safe smoking assessment questions listed on the form which would have determined Resident #4's ability to extinguish a lit cigarette ash and/or cigarette which had fallen safely. The DON stated that the signature listed on the form belonged to her and that she could not provide any explanation as to why; she did not complete Resident #4's smoking assessment according to the facility's policy. The DON also told the surveyor that there were currently 23 residents who smoked residing at the facility and according to their smoking assessments 12 of them could smoke un-supervised, and 11 required staff supervision. The DON added that the facility had a 24-hour unwritten policy that staff was always present while residents were smoking in the courtyard. A review of the smoking contract/assessments in the presence of the DON and the CCCN dated from 12/2012 through 3/2016 revealed that the facility performed the initial smoking assessment for 23 residents who smoked. A review of 1 resident's smoking assessments, dated 12/18/12 revealed that the most recent quarterly assessment was performed on 7/3/2013. A review of 4 resident smoking assessments, dated from 1/2014 through 11/2014 revealed that their initial smoking assessments were completed and there was no evidence that subsequent quarterly assessments were done. Furthermore, a review of an additional 17 resident smoking assessments, dated from 1/2015 through 4/2016 revealed that the initial smoking assessments were completed for these residents however; there was no evidence that subsequent quarterly assessments were done according the facility's policy for these residents. One resident was admitted to the facility in July 2016 and was not due for an assessment. The DON and the CCCN both stated that they did not know why the smoking re-assessments were not done. The CCCN stated that the facility had to re-educate the staff on the facility's smoking policy and re-assess all of the residents who smoked. According to the facility's policy titled Smoking Policy Contract, revised 1/2015 revealed the following: In an effort to ensure the safety of residents of the facility, resident who wish to smoke are provided the use of the enclosed patio area as the only designated smoking area. Residents who smoke are to utilize the ashtrays provided in the smoking area. These are the following restrictions for the privilege of smoking at the facility. 1. Upon admission a member of the Interdisciplinary (IDC) Team will meet with the resident to determine if they are responsible to smoke without being monitored. 2. Only residents declared responsible are allowed to have cigarettes, lighters or matches of any kind, at this time. 3. There will be no smoking in the building, in resident rooms or bathrooms. 4. There will be no buying, giving or selling of cigarettes to other resident for safety purposes. Lighting of other resident's cigarettes are also not allowed. 5. Smoking is in the designated enclosed patio area only. Ashtrays must be used for cigarettes only. 6. All smoking residents will be assessed quarterly for continued smoking policy compliance. The immediate jeopardy was corrected on 8/10/16 at 2:50 p.m. based on an acceptable plan of correction. 1. The cups with cigarettes butts were removed from smoking area and was given to administration by surveyor to be properly disposed of. Area was checked to confirm that no other cigarette butts were improperly disposed. 2. All residents have a potential of being effected when cigarettes are not extinguished in a proper container. All nine residents in the smoking area were immediately in-serviced on proper disposal of and extinguishing cigarettes. All smokers beginning today 8/10/16 will be reassessed and this process will be on going until completed. All residents will be monitored for safety of extinguishing cigarettes by smoke monitor, administrator and shift supervisor to ensure compliance daily all shifts. 3. An in-service was done immediately with smoke aides on ensuring all residents discard their cigarettes in appropriate containers. All smoke monitors and all other staff on all three shifts will be in-serviced as well and on-going. Residents will be reminded by smoke monitor and staff while in smoking area and in monthly resident council meeting what is an acceptable device to dispose of cigarettes. 4. The administrator or Quality Assurance (QA) aide and shift supervisor will monitor smoking area daily on all three shifts for 24 hours then daily to ensure proper disposal of cigarettes. Smoking assessments will be reviewed periodically by activity staff and will be monitored by administrator beginning 8/10/16 and on-going. N.J.A.C. 8:39-4.1(a)11

Based on observation, interview and record review, it was determined that the facility failed to make arrangements or communicate with a community based social service agency already involved with the affected resident for the resident's safe discharge from the facility. The facility was ready to discharge a homeless resident from the facility The resident was "scared to death" when told about the impending discharge. This deficient practice was identified for Resident #17, 1 of 1 residents reviewed for discharge planning, and was evidenced by the following: During the initial tour of the facility on 1/14/15 at 12:30 p.m. a facility nurse told the surveyor that Resident #17 had met his/her therapy goals on 1/13/15 and was being discharged that day. The resident did not leave on 1/14/15 as originally planned. On 1/15/15 at 11:15 a.m. the surveyor was approached by a woman who stated she was with The Cumberland County Guidance Center (CCGC) PATH organization. She stated she was representing Resident #17 who was homeless prior to admission to the facility. The PATH worker told the surveyor that Resident #17's discharge orders were written on 1/14/15 and the nurse had already gone over instructions with the resident on how to take medications after his/her impending discharge that day (1/15). The surveyor was told by the CCGC representative "I am very upset, the Administrator is telling me he/she has to leave now but there is no place to take him/her. The Administrator is telling me to drop the resident off at the emergency room and I will not do that. I would take him/her to a motel but the therapy discharge note says he/she gets dizzy upon standing and cannot walk without someone assisting. In good conscience, I cannot take him/her out of here. I said I was going to tell the State and he (the administrator) said 'you don't have to do that'." On 1/15/15 at 11:20 a.m. the surveyor observed the resident out of the room and seated in a dayroom at the end of the nursing unit. When interviewed at that time, the resident said he/she had nowhere to go as the facility's Social Worker (SW) had not arranged for him/her to go into the community because she thought discharge planning was the responsibility of the PATH worker. The surveyor's review of all the facility's SW progress notes on 1/15/15 at 11:30 a.m. indicated the facility's SW reliance on PATH to find placement at discharge. The resident also corroborated what the PATH representative had stated regarding what was said by the facility's Administrator. Resident #17 said "He (the Administrator) was just in here and was adamant that I leave now. He keeps saying that he will help get me into the CCGC worker's car and she can drop me off at the emergency room . That way he won't have to "take the hit" for me being here without insurance. He said they have discharge planners and social workers there and that would be the best thing for me to do." The resident said "He said, whatta you want, for us to go broke?" On 1/15/15 at 11:30 a.m. the surveyor spoke to the nurse who was preparing Resident #17 for discharge. The nurse stated that she went over all medication and their distribution times with the resident and a 2 week supply of medication was ready to go with the resident upon leaving the facility. According to the medical record Resident #17 was living in a trailer with no heat or water and this had been reported to a community resource center. When found there, he/she had been having seizures and was found to also have an electrolyte imbalance and was hospitalized . Resident #17 was admitted to the facility for rehabilitation on 12/4/14 from the hospital. [DIAGNOSES REDACTED]. On 1/15/15 at 12:30 p.m. the surveyor interviewed the facility's SW along with the Administrator. The SW indicated that she made no referrals to the resources in the community because she was "under the impression that PATH was supposed to do it." The Administrator stated "It was (the PATH worker) who was supposed to find him housing, not us." He stated that the facility should not have to "take the hit" for PATH not placing him. After the 1/15/15 at 12:30 p.m. meeting the SW then began to look for appropriate placement and a safe discharge into the community based on notes she showed the surveyor at 2 p.m. that day. Also, she then began the process of working to help Resident #17 get signed up for Social Security benefits. The plan to send him/her to the emergency room was stopped and Resident #17 was still at the facility when the survey ended on 1/23/15. On 1/15/15 at 1 p.m. the surveyor reviewed the facility's "Discharge Instructions for Care." The form was dated 1/14/15 and was signed by the facility SW on 1/15/15. The form included check off choices of Discharge to Home or to a Care Facility. Discharge to home was checked off. Also, the space to write "Transportation Arrangement" to get to the "home" was blank. The signed discharge form also indicated that an appointment was scheduled for Resident #17 to see a doctor at 1:45 p.m. on 1/15/15. On 1/20/15 at 10 a.m. the surveyor met with the Director of Therapy. She stated that the resident had not met their goals as insurance had stopped paying. The surveyor referred her to the therapy discharge note dated 1/13/15 which indicated Resident #17 got dizzy upon standing and could not walk without contact guard assistance and therefore, could not be alone. She stated "Yes, (Resident #17) could have gotten better with more therapy, it's a shame." On 1/20/15 at 11:15 a.m. the surveyor met with Resident #17 who was placed in a room on a different unit. When asked about the events that had occurred on 1/15/15, Resident #17 stated "I was scared to death, you know, feeling they were going to put me out the door. Or make me the hospital's problem. I felt like dirt. Like I was just a number. It was disgusting. I know that if the State wasn't here, he would have done it. He was adamant." On 1/20/15 at 12:05 p.m. the surveyor called the Advanced Practice Nurse (APN) who gave the order to "discharge to home" on 1/14/15. The surveyor asked the APN if she knew Resident #17 did not have a home. She stated she did not know the resident very well and was told by the facility SW yesterday that the PATH worker was taking care of discharge. (This was after the order to discharge home was documented.) She rescinded the discharge order that day, 1/20/15. On 1/23/15 at 11 a.m. the surveyor interviewed the facility SW about the information she had entered on the Minimum Data Set assessment tool in Section Q. The facility SW documented on that MDS dated [DATE], thirteen days after admission, that Resident #17 had no family, no guardian and no legal representative. Also that the resident's goal was to be discharged into the community. In the section asking if a referral to the community was made, the facility SW wrote "No." The facility SW told the surveyor she wrote that because "I thought she (the community SW) was going to do it." NJAC 8:39 - 27.1(a)

C#NJ Based on observations, interviews, review of medical records and other information, it was determined that the facility failed to ensure that the attending physician's orders [REDACTED].#1, #2, #3). Resident #1 did not receive a Podiatry assessment in a timely manner and developed "grossly elongated and painful toe nails". The evidence of this deficiency included: 1. According to the Minimum Data Set (MDS), an assessment tool dated 6/10/11, Resident #1 was cognitively intact, rejected care on a daily basis and was totally dependent on staff for most activities of daily living. She also had an impairment in range of motion to her lower extremities. The [DIAGNOSES REDACTED]. The Interdisciplinary Care Plan updated 3/11/11 and 6/13/11, showed a goal that the Resident "will be free of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]". A wound monitoring form dated 7/28/11, showed a "fungal nail" on the "left 3rd toe". Review of the monthly physician's orders [REDACTED]. The Physician's Progress Notes dated 6/8/11, included a "Podiatry consult" order. Another entry dated 7/18/11, indicated an "Acute Visit" and that the "...left foot 3rd toe mycotic nail - painful." The "P (plan)" included a Podiatry Consult. physician's orders [REDACTED]. Another entry dated 7/17/11 noted "Podiatry consult to left foot 3rd toe - as soon as possible". Review of the Interdisciplinary Progress Notes (IPN) dated 7/19/11 at 3:00pm, indicated a complaint of dry patches on the right toes. an order for [REDACTED]. Review of a Report of Consultation form dated 8/1/11, showed that the Resident was not in the facility when the Podiatrist visited and that he would return at a later date. A second Report of Consultation form dated 8/8/11, revealed a podiatry assessment at the physician's request for a C/O (complaint) of "grossly elongated thick and painful toe nails B/L (bilaterally)". A Notation indicated a "blood sugar" reading of "274" on 8/5/11". The Podiatrist "debrided Mycotic nails B/L (bilateral) and applied [MEDICATION NAME] to all nails." The Surveyor accompanied by the Assistant Director of Nurses (ADON) observed the Resident's feet and toes at 9:35am, and the ADON confirmed that there was still some fungal areas on some of the toe nails. At 10:25am, the Resident stated that the Podiatrist visited for the first time on 8/8/11 and cut her toe nails. She further stated that a fungus infection grew because the Podiatrist didn't visit, although she had been asking to see him, but now her toes feel better and were "no longer painful". During another interview with the ADON at 12:30pm, she stated that 1 of 3 Podiatrists who service the facility, visits on a monthly basis. She also stated that she could not find any Podiatry consults other than the consult done on 8/8/11. She further stated that the Resident "may have" refused the Podiatry consult, however there was no indication of this in the medical record. 2. The MDS dated [DATE], reflected that Resident #2 had moderate cognitive impairment and was extensive assist on staff for most activities of daily living. The [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Although the Resident's toe nails were observed to be trimmed, she stated at 9:28am that a Podiatrist had not visited her since admission into the facility. The facility was unable to provide, at the time of survey, evidence that the Resident received the services of a Podiatrist as ordered in the Physician order [REDACTED]. 3. Resident #3 as indicated by the MDS dated [DATE], had severe cognitive impairment and extensive assist with most activities of daily living. The [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. The Resident's right toe nails were observed at 9:15am, to be clean and trimmed. The facility was unable to provide, at the time of survey, evidence that the Resident received the services of a Podiatrist as ordered in the Physician order [REDACTED]. The Policy and Purpose indicated that "The facility assures that the services of a Podiatrist are available for routine and emergency care, to all residents." "To provide residents with proper foot and nail care to prevent or treat problem conditions." The Procedure indicated "1. Upon admission ... Admissions assigns a Podiatrist. A face sheet gets faxed to the selected Podiatrist for initial followup and treatment thereafter." Also, "3. If a situation requiring emergency foot care arises, notify the podiatrist as soon as possible." NJAC: 27.1(a)